   ALSO ALSO  ALSO ALSO Provider Instructor Approved Advisory Five year status Candidate Instructor Faculty Must attend an Attend an ALSO Must maintain ALSO Provider Five year status Instructor Course, then Approved Instructor Course and Must instruct in three instruct one course status to maintain successfully courses (ALSO and/or (ALSO or BLSO) within Advisory Faculty complete the BLSO) every five one year and receive status written and skills years to maintain recommendation/ testing. status approval for Approved Instructor status

ALSO Providers and Instructors are responsible for their status maintenance. Due to the ALSO database being programmed with the above requirements, no exceptions can be made. Please call or email ALSO staff if you would like to verify your status at any time.

ALSO Provider - Participation in an ALSO Provider Course and successfully completing the written examination and megadelivery testing station designates the participant as an ALSO Provider . To maintain Provider status, the individual must attend another provider or refresher course before their five-year expiration date. An ALSO Provider is eligible to be course director for an ALSO Provider Course. The ALSO Advisory Board recommends that the course director be an ALSO Approved Instructor or Instructor Candidate although it is not mandatory. Instructor Candidate - An ALSO Provider is eligible to attend an ALSO Instructor Course. Participation in an ALSO Instructor Course designates the provider as an ALSO Instructor Candidate. The instructor candidate must teach in an ALSO or BLSO Provider course within one year of taking the instructor course and be evaluated and recommended by an ALSO Advisory Faculty for Approved Instructor status. The Instructor Candidate Evaluation form must be submitted by the instructor candidate to the ALSO Program Department before the one year expiration date of the candidate. ALSO Approved Instructor - An instructor candidate whose teaching skills have been evaluated by an advisory faculty and has been recommended and approved to be an ALSO Approved Instructor. To maintain Approved Instructor status, the individual must teach in three courses (ALSO and/or BLSO) every five years. The five year cycle begins the day the provider completes the ALSO Instructor course. Provider status is automatically extended to meet the approved instructor expiration date, and individual will be exempt from taking the provider course as long as they maintain ALSO Approved Instructor status by teaching in three courses every five years. If the Instructor teaching requirements are not met, the ALSO status will expire and the individual will need to start the ALSO status life cycle again. ALSO Advisory Faculty - To be considered for Advisory Faculty status, the individual must be recommended by an advisory faculty, complete the required Advisory Faculty Application and submit, with other required documents to ALSO Staff . Maintaining ALSO Approved Instructor status is required for applying for an ALSO Advisory Faculty status. This faculty position requires that the person be considered an “expert” on all aspects of the ALSO Provider Course. It is mandatory that there be an ALSO Advisory Faculty present at every provider course to maintain quality, consistency, and ensure that the course adheres to all the requirements set forth by the ALSO Advisory Board . An individual serving as advisory faculty may not serve in any other role during a course.

To find out more about the ALSO program, upcoming courses or to find the Instructor Candidate Evaluation and/or Advisory Faculty Applications, please visit www.aafp.org/also .

ALSO Program Staff: 1-800-274-2237 x8722

6/25/14 Advanced Life Support in Obstetrics (ALSO®) ALSO Course Syllabus

Advanced Life Support in Obstetrics Advisory Board, 2013 – 2014 David Gregory, MD, Chair Patricia Fontaine, MD Jennifer Frank, MD Helen Welch, CNM Harry Taylor, MD Marty Olsen, MD Tony Ogburn, MD

The American Academy of Family Physicians wishes to acknowledge the initial development of the ALSO Program by the University of Wisconsin Department of Family Medicine, and the original national ALSO Development Group of family physicians, obstetricians, and nurses, which formed in 1991. The ALSO Program, originally conceptualized by James R. Damos, MD, was developed under the leadership of Dr. Damos and John W. Beasley, MD The American Academy of Family Physicians acquired the ALSO Program in 1993.

The 2000 edition of the ALSO Course Curriculum, added levels of evidence for recommendations and references used in the new curriculum. The curriculum demonstrates the evidence, and quality of that evidence, on which any recommendations of care are based.

The 2006 edition of the ALSO syllabus was an ongoing process. As chapters were revised, they were replaced in the syllabus. If a chapter currently did not need to be revised, a one page evidence based addendum was published.

The current ALSO Syllabus continues to be an ongoing process. Chapters will continue to be revised, but one page addendums will only be published if an important/key evidence based practice recommendation becomes available that would significantly alter a change in practice.

— Overview — 1 Managing Editor Mark Deutchman, MD Professor, Department of Family Medicine 2009 Edition University of Colorado Health Sciences Larry Leeman, MD, MPH Denver, Colorado Professor University of New Mexico School of Medicine Steven H. Eisinger, MD, FACOG Albuquerque, New Mexico Professor of Family Medicine and Associate Professor of Obstetrics and Gynecology The University of Rochester Family Medicine Program Associate Editors Rochester, New York Lee Dresang, MD Ann Evensen, MD Departmental Maternity Care Assistant Professor, CHS Clinical Coordinator University of Wisconsin School of Medicine and Public University Wisconsin School of Medicine and Public Health Health Jeffrey Quinlan, MD, CAPT, MC, USN Verona, WI Director, University Family Health Center Patricia Fontaine, MD, MS Uniformed Services University Assistant Professor Bethesda, Maryland Department of Family Practice and Community Health University of Minnesota Medical Illustrator Minneapolis, Minnesota Larry Howell Jennifer Frank, MD, FAAFP Howell Graphics and Illustration Assistant Professor (CHS), Department of Family Medicine Blue Springs, Missouri University of Wisconsin School of Medicine and Public Health Medical Director Current Authors UW Health Fox Valley Family Medicine Clinic Appleton, Wisconsin Karen Ailsworth MD, MS, FAAP Pediatrician and Clinical Assistant Professor Robert W. Gobbo, MD Baraboo Family Practice Residency Faculty Providence Family Medicine Residency Rural Training Program Clinical Associate Professor, Family Medicine St. Mary’s/Dean Venture, Baraboo, Wisconsin Portland, Oregon Affiliate University of Wisconsin Kim Hinshaw, M.B., B.S., MRCOG Department of Family Medicine-Madison Consultant Obstetrician and Gynecologist Janice Anderson, MD Sunderland Royal Hospital, NHS Trust Forbes Family Practice Residency Program Sunderland, Tyne & Wear Monroeville, Pennsylvania England Lesley Ann Atwood, MD, FAAP Kristi K. Miller, RN, MS Clinical Associate Professor System Director, Clinical Safety Department of Family Medicine Fairview Health Services University of Minnesota St. Paul, Minnesota Hastings, Minnesota Neil J. Murphy, MD, FACOG R. Eugene Bailey, MD Chief Clinical Consultant, OB/GYN Assistant Professor Indian Health Science Center for Evidence-Based Practice Alaska Native Medical Center Department of Family Medicine SUNY Upstate Medical University Stephen Ratcliffe, MD, MSPH Syracuse, New York Program Director Lancaster General Family Medicine Residency Timothy P. Canavan, MD, MSc Lancaster, Pennsylvania Attending Perinatologist Greenwich Hospital William G. Sayres, Jr, MD Yale New Haven Health System Medical Center Chief 5 Perryridge Road Riverfront Medical Center Greenwich, Connecticut 06830 Group Health Cooperative Spokane, Washington Brendon Cullinan, MD Senior Medical Director for Primary Care Sara G. Shields, MD, MS Hennipen County Medical Center, Minneapolis, Minnesota Assistant Professor of Clinical Family Assistant Professor, University of Minnesota Medicine and Community Health Department of Family Medicine University of Massachusetts Family Health Center of Worcester James R. Damos, MD Worcester, Massachusetts Baraboo Family Practice Residency Rural Training Program St. Mary’s/Dean Venture David Turok, MD, MPH Baraboo, Wisconsin Assistant Professor Affiliate University of Wisconsin Department of Family Departments of Obstetrics and Gynecology Medicine-Madison and Family and Preventive Medicine University of Utah

2 — — Overview Fifth Edition Preface

The ALSO Provider Course is an educational program designed to assist health professionals in developing and maintaining the knowledge and skills needed to effectively manage the emergencies which arise in maternity care. The course includes required syllabus reading, lectures and hands-on workstations. Evaluation is by a written exam and skills assessment stations. There are many appropriate ways of managing emergencies. The treatment guidelines presented in ALSO do not necessarily represent the only way to manage problems and emergencies. Instead, these guidelines are presented as reasonable methods of management in obstetrical emergencies. Each maternity care provider must ultimately exercise his or her own professional judgement in deciding on appropriate action in emergency situations. Completion of the ALSO Provider Course does not imply competency to perform the procedures discussed in the course materials.

OVERALL COURSE OBJECTIVES 1. Discuss methods of managing pregnancy and birth urgencies and emergencies, which may help standardize the skills of practicing maternity care providers. 2. Demonstrate content and skill acquisition as demonstrated by successful completion of the course written examination and megadelivery testing station.

CDC RECOMMENDATION The Centers for Disease Control recommend universal precautions be used in all situations where a risk of exposure to blood or bodily fluids is present, and the potential infectious status of the patient is unknown. All bodily fluids (blood, urine stool, saliva, vomitus, ect.) should be treated as potentially infectious. Universal precautions should always be followed in pregnancy and birth care.

COPYRIGHT The American Academy of Family Physicians (AAFP), owns the ALSO copyright and trademark on all of the course materials, including the syllabus, slide set and written examination. Use of portions of the materials outside of an authorized ALSO course is strictly prohibited with out prior written approval from the AAFP.

COURSE DISCLAIMER The material presented at this course is being made available by the American Academy of Family Physicians for educational purposes only. This material is not intended to represent the only, nor necessarily best, methods or procedures appropriate for the medical situations discussed, but rather is intended to present an approach, view, statement, or opinion of the faculty which may be helpful to others who face similar situations. The AAFP disclaims any and all liability for injury, or other damages, resulting to any individual attending this course and for all claims which may arise out of the use of the techniques demonstrated therein by such individuals, whether these claims shall be asserted by physician, or any other person. Every effort has been made to assure the accuracy of the data presented at this course. Physicians may care to check specific details, such as drug doses and contraindications, etc., in standard sources prior to clinical application. This Course has been determined to be a Level 2 classification under the AMA/PRA Credit and Classification Guidelines. The AAFP does not certify competence upon completion of the ALSO Provider Course, nor does it intend this course to serve as a basis for requesting new or expanded privileges.

— Overview — 3

2000 Edition Evidence Based Curriculum Neil Murphy, MD

The quality of the studies was evaluated according to the U.S. Preventive Services Task Force and the Canadian Task Force on Preventive Health Care criteria:

LEVELS OF EVIDENCE — 2000 EDITION Level I Evidence from at least one randomized controlled trial. Level II-1 Evidence from well designed controlled trials without randomization. Level II-2 Evidence from well designed observational studies, eg., case control or cohort studies, preferably from more than one center or research group. Cohort study: individuals who have already been exposed to the risk factor or intervention are compared to individuals who have not been exposed to the risk factor or intervention and are followed longitudinally to observe for differences in outcome. Case control study: researchers review cases assembled on the basis of their outcome (disease), and compare them with controls to determine whether there is an association between a disease and an exposure. Level II-3 Time series with or without intervention and dramatic results from uncontrolled studies. Level III Expert opinion, clinical experience, descriptive studies, case reports, reports of expert committees. From these ratings come an assessment of the strength of the recommendation, which you will see in the text and summarized in a table at the end of each chapter, as follows:

STRENGTH OF RECOMMENDATION — 2000 EDITION Category A There is good evidence to support the recommendation. Category B There is fair evidence to support the recommendation. Category C There is insufficient evidence to support the recommendation, however the recommendation may be made on other grounds. Category D There is fair evidence against the recommendation. Category E There is good evidence against the recommendation.

4 — — Overview

2006 – Current Edition Evidence Based Curriculum

The current edition of the ALSO Syllabus and one page evidence based addendums use the Strength of Recommendation Taxonomy (SORT) to determine evidence based recommendtions:

Strength of Recommendation Definition A Recommendation based on consistent and good-quality patient-oriented evidence B Recommendation based on inconsistent or limited-quality patient-oriented evidence C Recommendation based on consensus, usual practice, opinion, disease-oriented evidence based series for studies of diagnosis, treatment, prevention, or screening

A summary of recommendations will follow each chapter and will form the basis for the one page addendums. In deciding which points to choose for summary recommendations, authors and editors gave priority to recommendations that were high quality (SORT A).

SORT B recommendations were also included when they had important clinical implicaitons or were related to common clinical practices. SORT C recommendations only warrant mention in the summary, if the author/editor felt there was exceptional relevance for clinical practice.

— Overview — 5 Author and Editor Disclosure

The AAFP has selected, and provided funding for, all authors and editors of this syllabus. According to AAFP policy, all relationships between authors, editors and proprietary entities that may have a direct interest in the subject matter of their work will be disclosed. • Mark Deutchman MD, has disclosed that he has financial interests in the Challenger Coorporation for a video on cesarean delivery and in Cooper Surgical for a patent on a vacuum extractor. • Steve Ratcliffe, MD, has disclosed that he has an affiliation/financial interest with Hanley and Belfes; Publishers, as Chief Editor of the book “Prenatal and Perinatal Care in Family Practice.”

The following authors and editors have returned disclosure forms indicating they have no affiliation or financial interest in any organization(s) that may have a direct interest in the subject matter of this continuing medical education presentation.

Karen Ailsworth, MD Lee Dresang, MD Lawrence Leeman, MD Janice Anderson, MD Steven H. Eisinger, MD Neil J. Murphy, MD Lesley Atwood, MD Ann Evensen, MD Jeff Quinlan, MD R. Eugene Bailey, MD Patricia Fontaine, MD William Sayres, MD Timothy Canavan, MD Jennifer Frank, MD Sara Shields, MD, MS Brendon Cullinan, MD Robert Gobbo, MD David Turok, MD James R. Damos, MD Kim Hinshaw, RCOG

DECLARATION The ALSO Program is based on an adult learning model whereby participants prepare through advanced reading of the ALSO syllabus and take responsibility for their own learning before and during a provider course.

Instructors, course directors and advisory faculty, are expected to approach learners in a positive, constructive, and respectful manner and to have demonstrated these attributes during the training of new providers. The ALSO program requests and expects honest feedback to instructors regarding their effectiveness. The program reserves the right to remediate or terminate instructor-status of individual faculty who do not model these attitudes and approaches.

6 — — Overview Chapter A First Trimester Pregnancy Complications slide 1 Mark Deutchman, MD Amy Tanner Tubay, MD David Turok, MD

Published August 2010

Objectives slide 2 After completing this chapter, participants will be able to: • Discuss the value of hCG sonographic discriminatory criteria in diagnosing first trimester pregnancy complications. • Describe the process, diagnosis and management of miscarriage. • Describe the process, diagnosis and management of ectopic pregnancy. • Describe the process, diagnosis and management of gestational trophoblastic disease. slide 3 • Describe the spectrum of psychological reactions to early pregnancy loss. • Describe the techniques of suction curettage for the treatment of incomplete miscarriage.

Introduction slide 4 Complications of the first trimester of pregnancy are common. About fifteen percent of clinically recognized pregnancies miscarry spontaneously and estimates of losses prior to clinical recognition reach nearly 50 percent.1 In addition to miscarriage, vaginal bleeding may be associated with ectopic pregnancy, trophoblastic disease, cervical bleeding from causes unrelated to pregnancy or may occur in pregnancies that proceed otherwise uncomplicated.

Normal First Trimester Pregnancy Progress and Discriminatory Criteria slide 5 Clinically, pregnancy is dated from the first day of the last normal menstrual period (LMP), an observable event, rather from than the conception date. Conception is approximately two weeks later. All gestational landmarks in this chapter are based on menstrual dating; embryology textbooks commonly use conception dating which is two weeks less.

The placenta produces human chorionic gonoadotropin (hCG) after implantation. Implantation slide 6 occurs at 23 menstrual days, which is about eight days after conception. Commonly available urine pregnancy tests can detect the beta subunit of hCG at levels of 50 to 100 mIU/ml IRP (International Reference Preparation) and some can detect hCG at levels as low as 20 mIU/ml. Serum tests can detect hCG as low as 5 mIU/ml. While it is therefore technically possible to detect pregnancy prior to a missed period, the majority of over the counter home pregnancy tests will not be positive until the first week after a missed menstrual period.2 Quantitative serum hCG levels should double every two to three days during weeks four to eight in normal early pregnancy. Falling levels, or those that plateau are strong evidence of impending poor outcome but do not distinguish between spontaneous abortion and ectopic pregnancy.3,4,5 Slide 6 demonstrates hCG patterns in normal first trimester pregnancy versus miscarriage and ectopic pregnancy.

— Chapter A: First Trimester Pregnancy Complications — 1 A single serum progesterone level has been shown to be effective in predicting early pregnancy location slide 7 when ultrasound findings are inconclusive.6,7 With this method a progesterone level of less than five nanogram/ml is more likely to be associated with a poor pregnancy outcome (spontaneous abortion or ectopic pregnancy) while a progesterone level of greater than 25 nanogram/ml is strongly associated with a living intrauterine pregnancy. However, this method is rarely employed as the use of serial quantitative hCG and transvaginal ultrasound have proven to be the most cost effective strategy for diagnosing ectopic pregnancy.8

The gestational sac first becomes visible sonographically during the fifth menstrual week as a 2 to 5 mm slides 8-11 sonolucent area surrounded by an echogenic ring of chorionic villi. This early gestational sac is visible only using a high frequency transducer (5 MHz or greater) and the transvaginal scan route. A small sonolucent fluid collection, or pseudosac, may also be present in cases of ectopic pregnancy, so additional features of a normal gestational sac can be sought including the “intradecidual sign” indicating that the gestational sac is embedded in the endometrium and not within the endometrial stripe. The yolk sac appears during transvaginal scanning during the sixth menstrual week and provides clear evidence of an intrauterine pregnancy. By the end of the sixth menstrual week, the “fetal pole” 2 mm to 8 mm in length with embryonic cardiac activity becomes visible during transvaginal scanning. All these sonographic landmarks are visible with transabdominal scanning about one week later than with transvaginal scanning.9

Discriminatory criteria based on clinical, hCG and sonographic findings are closely correlated and are displayed in Table 110,11 Ultrasonography is so helpful that, when it is readily available, many clinicians use it as a primary tool in the evaluating first trimester complications, leaving serum hCG and/or progesterone testing as a secondary tool to use only if sonographic findings are equivocal. The greatest diagnostic yield is obtained when first trimester ultrasonography is performed in combination with knowledge of the patient’s history, physical examination and any relevant laboratory tests that have already been performed. Routine ultrasound in early pregnancy appears to enable better gestational age assessment, earlier detection of multifetal pregnancies and earlier detection of multifetal pregnancies, however the benefits for other substantive outcomes are less clear.12

Table 1. Early Pregnancy Discriminatory Findings* slide 12 Menstrual Age Embryologic Event Laboratory and Transvaginal Sonographic Discriminatory Findings Three to four weeks Implantation Site Decidual thickening

Four weeks Trophoblast Peritrophoblastic flow on color flow Doppler

Must be present if bhCG > 1500 to 2000 mlU/mL (varies with Four to five weeks Gestational Sac sonographer experience and ultrasound quality)

Five to six weeks Yolk Sac Must be present if gestational sac mean diameter > 10 mm

Five to six weeks Embryo Seen when gestational sac mean diameter is > 18 mm

Five to six weeks Cardiac Activity Must be present if embryonic crown-rump length > 5 mm

*Adapted from Reference #10.

Once the embryo is visible sonographically, first trimester menstrual age is calculated from slide 13 crown-rump length using parameters such as those shown in Table 2. Between eight and 13 weeks, gestational age can be approximated using the simple formula: Menstrual age (weeks) = crown- rump length (CRL) in centimeters (cm) plus 6.5, or this alternate formula: Menstrual age (days) = crown-rump length in millimeters (mm) plus 42.

2 — — Chapter A: First Trimester Pregnancy Complications Table 2. Crown-rump Length and Menstrual Age

Crown-rump length Menstrual age Crown-rump length Menstrual age 0.2 cm 5.7 weeks 3.0 cm 9.9 weeks 0.4 cm 6.1 weeks 3.5 cm 10.4 weeks 0.6 cm 6.4 weeks 4.0 cm 10.9 weeks 0.8 cm 6.7 weeks 4.5 cm 11.3 weeks 1.0 cm 7.2 weeks 5.0 cm 11.7 weeks 1.3 cm 7.5 weeks 5.5 cm 12.1 weeks 1.6 cm 8.0 weeks 6.0 cm 12.5 weeks 2.0 cm 8.6 weeks 6.5 cm 12.8 weeks 2.5 cm 9.2 weeks 7.0 cm 13.2 weeks

MISCARRIAGE Table 3 defines the many terms that are commonly applied to early pregnancy loss.13,14 slide 14 Table 3. Terms Applied to Early Pregnancy Loss*

Embryonic Demise — an embryo > 5 mm without cardiac activity. (Replaces the unclear term “missed abortion.”) Anembryonic Pregnancy — presence of a gestational sac > 18 mm without evidence of embryonic tissues (yolk sac or embryo). This term is preferred to the older and less accurate phrase “blighted ovum.” Spontaneous Abortion — spontaneous loss of a pregnancy prior to 20 weeks gestation. May be further described as: • Incomplete — occurs when some but not all of the products of conception have passed • Complete — the complete passage of all products of conception • Septic — Incomplete abortion associated with ascending infectino of the endometrium, parametruim, adnexa, or peritoneum • Inevitable — bleeding in the presence of a dilated cervix, indicating that passage of the conceptus is unavoidable • Missed — The fetus or embryo has been dead for several weeks but no tissue has been passed. The cervix is closed. These patients often present with no growth in uterine size or no fetal heart tones being heard. Threatened Abortion — bleeding before 20 weeks in the presence of an embryo with cardiac activity and closed cervix. Subchorionic Hemorrhage — Ultrasonographic finding of blood between the chorion and uterine wall, usually seen in the setting of vaginal bleeding. Recurrent Pregnancy Loss — more than two consecutive pregnancy losses. The phrase “habitual aborter” ahs also been used in this setting but is no longer appropriate. Ectopic Pregnancy — pregnancy outside the uterine cavity, most commonly in the fallopian tube but may occur in the brad ligament, ovary, cervix or welsewhere inthe abdomen. Heterotopic Pregnancy — simultaneous intrauterine and ectopic pregnancy. Risk factors include ovulation induction, in vitro fertilization and gamete intra-fallopian transfer. Gestational Trophoblastic Disease, or Hydatidiform Mole — Complete mole: placental proliferation in the absence of a fetus. Most have a 46 XX chromosomal composition, all derived from paternal source. Partial mole: molar placenta occurring together with a fetus. Most are genetically triploid (69 XXX) Vanishing Twin — A multifetal pregnancy is identified and one or more fetuses later disappear. More commonly seen now that early ultrasound scanning is common. It this occurs early in pregnancy, the embryo is often reabsorbed, later occurrence results in a compressed or mummified fetus or amorphous material. *Adapted from References 13 and 14.

— Chapter A: First Trimester Pregnancy Complications — 3 MISCARRIAGE: PATHOPHYSIOLOGY, CLINICAL COURSE slides 15-19 AND DIAGNOSIS The cause of spontaneous abortion is rarely determined in clinical practice, but it is known that about half are due to major genetic abnormalities, usually trisomy, triploidy, or monosomy.15 Environmental factors linked to spontaneous abortion are shown in Table 4.

Table 4. Environmental Factors Linked to Spontaneous Abortion

Uterine anomalies Leiomyomata Incompetent cervix Tobacco, alcohol or cocaine Progesterone deficiency due to luteal phase defect Irradiation Maternal diethylstilbestrol (DES) exposure Advanced maternal age Infections Occupational chemcial exposure

Spontaneous abortion may present clinically in several different ways. Most commonly, vaginal bleeding and cramping are present, but occasionally, regression of pregnancy symptoms or lack of Doppler-detected fetal heart tones by 10 to 12 weeks are the first clinical signs in the setting of anembryonic pregnancy or embryonic demise.

Clinical examination should include palpation of the abdomen and pelvis. The size and position of the uterus, the location of any tenderness, the presence of rebound tenderness and the presence of masses should be noted. Adnexal tenderness and any masses should heighten concern for ectopic pregnancy, although a normal corpus luteum cyst may also be the cause.

If the patient’s last menses was at least nine to ten weeks ago, consider listening for the fetal heartbeat during the bimanual pelvic exam while elevating the uterus with the examining hand.

The speculum examination will reveal non-uterine causes of bleeding, the degree of cervical dilation and, if present, tissue being passed. The quantity of blood in the vault and the source of bleeding (from the os vs. other sites) should be noted. If an intact gestational sac, an embryo, or the characteristic fronds of chorionic villi are seen, miscarriage is proven and ectopic pregnancy is virtually ruled out except in the rare case of simultaneous intrauterine and ectopic pregnancy (heterotopic pregnancy). To look for chorionic villi, rinse and float the tissue with saline. Low magnification, backlighting and “teasing” the tissue may help. Passed tissue should be submitted for pathological examination which is definitive in questionable cases. Slide 19 shows this finding.

If tissue is seen at the cervical os, miscarriage is inevitable. A ring forceps may be used to gently remove it. More aggressive attempts to remove partially expelled tissue should be preceded by discussion with the patient, informed consent and administration of analgesia or sedation.

When the diagnosis is not clear by clinical findings, transvaginal scanning is essential for accurate diagnosis.

4 — — Chapter A: First Trimester Pregnancy Complications slides 20, 21 There are two ultrasonographic findings diagnostic of early pregnancy failure.14 The first is the presence of a gestational sac with a mean sac diameter of 20 mm or greater without an embryo. This is diagnostic of an anembryonic pregnancy (Slide 20). The second finding is that of an embryo five mm or greater in crown-rump length without cardiac activity, diagnosing an embryonic demise. If there is any doubt about the sonographic findings, close follow-up and re-examination in four to seven days is reasonable if the patient is stable. Both the gestational sac and the embryo if present should each grow at the rate of approximately 1 mm/day, thus allowing for appreciable interval change in that time period. When ultrasound reveals a heartbeat in a patient who is bleeding, the probability of miscarriage is between 2.1 percent for women under 35 years of age to 16.1 percent in women over 35 years of age.16

Complete, spontaneous miscarriage may result in an empty uterus with a bright “endometrial stripe” indicating the uterine walls have collapsed back against each other and that the miscarriage is complete. When the patient has a history of passing tissue or clots, this finding can help determine if the miscarriage is complete. Echogenic material within the endometrial cavity commonly creates an endometrial stripe > 15 mm following medical treatment of early pregnancy failure.17

Septic abortion should be assumed when the patient is febrile or has excessive uterine or adnexal tenderness, or signs of peritonitis. A previous history of attempted therapeutic abortion or illegal abortion that may have left tissue behind or perforated the uterus should be sought, an extremely rare event where abortion services are legal and safe.

slide 22 In subchorionic hemorrhage, a gestational sac and embryo will be present but sonography will reveal a hematoma between the chorion and uterine wall. When subchorionic hemorrhage is seen by ultrasound, the likelihood for miscarriage averages about ten percent, even when a heartbeat is detected, and varies by maternal age, size of the hematoma and gestational age.18 Therefore the patient should be warned to expect bleeding.

The quantity of bleeding only predicts pregnancy loss when it is heavy. A prospective analysis of 4,510 women who were followed in the early first trimester showed that 1,204 (27 percent) had some bleeding or spotting. There was no increase in risk of miscarriage in early pregnancy when there was spotting or light bleeding. However risk of miscarriage increased significantly in the eight percent of women who reported heavy bleeding. This was the only group to have an increased risk of miscarriage (Adjusted OR 2.84, 95% CI 1.82-4.43).19

MISCARRIAGE: MANAGEMENT If ultrasound reveals an intrauterine pregnancy with cardiac motion, the patient may be followed with cautious optimism and an explanation that there are no known interventions to prevent miscarriage.

When physical examination reveals incomplete miscarriage, the patient must choose between expectant, medical or surgical management. The majority of first trimester miscarriages occur completely and spontaneously without intervention. Although surgical intervention in the form of sharp or suction dilatation and curettage have been used traditionally and liberally, expectant management and medical treatment are valid options.20,21,22 Women who are experiencing excessive bleeding, pain, or have infection benefit from medical or surgical intervention.20,21 In an observational study 22 expectant management led to spontaneous completion of 91 percent of cases of incomplete miscarriage, 76 percent of missed abortions and 66 percent of anembryonic pregnancies

— Chapter A: First Trimester Pregnancy Complications — 5 within 14 days of diagnosis. Women who have not completed the miscarriage for a long period of time may prefer medical or surgical intervention. Her emotional state and personal preferences are important in choosing the course of action.

Clinical trials comparing expectant management with misoprostol and misoprostol with surgical treatment conclude:23,24,25 slides 23-26 • In incomplete miscarriage, both expectant and medical treatments with misoprostol are highly successful. • In missed abortion, medical treatment with misoprostol and surgical treatment are more effective than expectant treatment. • Typical misoprostol dosages are 600 micrograms orally or 600 to 800 micrograms vaginally • Women treated with misoprostol have more bleeding but less pain than those treated surgically. • Women treated expectantly have more outpatient visits than those treated with misoprostol. • Surgery is associated with more trauma and infectious complications than misoprostol treatment. • Misoprostol has fewer gastrointestinal side effects when given vaginally than when given orally.

As a result of trials on medical management of miscarriage, a change to less surgical management has been suggested, even though use of misoprostol for this purpose is not approved by the Food and Drug Administration.26

There is no evidence supporting the use of prophylactic antibiotics in early pregnancy failure,27 although there is such evidence for induced abortion. When misoprostol is used for medical abortion, the incidence of infectious complications is reduced by administering the drug by the buccal route and by administering doxycycline 100 mg twice daily for seven days.28 It is unclear whether it is the use of antibiotics or the change in the route of misoprostol administration that resulted in the lowered incidence of infection. It is also not clear whether this is also true when misoprostol is used to treat early pregnancy loss. It is also reasonable for a woman to change treatment course and mix the three treatment options. Women commonly choose a period of expectant management followed by medical therapy with misoprostol if they no longer desire to wait. This could also be followed by dilation and curettage if medical therapy is not successful.

After a miscarriage it is customary to recommend a brief period of contraception before attempting another pregnancy. However, this practice is not supported in the literature. A prospective study found no statistically significant difference of recurrent miscarriage in women who had interpregnancy intervals < six months versus those who had longer intervals.29 For patients desiring long- term contraception, an intrauterine device placed immediately after spontaneous or induced first trimester abortion is safe and effective.30

6 — — Chapter A: First Trimester Pregnancy Complications ECTOPIC PREGNANCY: PATHOPHYSIOLOGY AND RISK FACTORS Ectopic pregnancy is usually located in the fallopian tube but rarely may occur in the broad slides 27, 28 ligament, ovary, cervix at the site of a prior hysterotomy or elsewhere in the abdomen. Ectopic pregnancy can result in impairment or loss of fertility and, due to internal hemorrhage, remains the second most common cause of maternal mortality. Early diagnosis is the key to preventing morbidity and mortality and preserving fertility. All health care providers who care for childbearing age women should have an active working knowledge of ectopic pregnancy, and should have a high index of suspicion in any woman who presents in early pregnancy with bleeding and/or pain. Risk factors are shown in Table 5, but many ectopics occur in women without risk factors.

Table 5. Risk Factors for Ectopic Pregnancy

History of tubal surgery, including tubal ligation and/or reanastomosis of the tubes after tubal ligation

History of tubal infection including pelvic inflammatory disease

Contraception with progestin only pills or intrauterine devices History of in utero exposure to diethylstilbesterol

History of pervious ectopic pregnancy

slides 29-32 ECTOPIC PREGNANCY: SIGNS, SYMPTOMS AND DIAGNOSIS Pain and vaginal bleeding are the hallmark symptoms of ectopic pregnancy. Pain is almost universal; it is generally lower abdominal and unilateral. Bleeding is also very common following a short period of amenorrhea. Physical exam may reveal a tender adnexal mass, often mentioned in texts, but noted clinically only 20 percent of the time. Furthermore, it may easily be confused with a tender corpus luteum of a normal intrauterine pregnancy. Finally signs and symptoms of hemoperitoneum and shock can occur, including a distended, silent, “doughy” abdomen, shoulder pain, bulging cul- de-sac into the posterior fornix of the vagina, and hypotension.

Initially, serum hCG rises, but then usually plateaus or falls. Transvaginal ultrasound scanning is a key diagnostic tool and can rapidly make these diagnoses: 1. Ectopic is ruled out by the presence of an intrauterine pregnancy with the exception of rare heterotopic pregnancy 2. Ectopic is proven when a gestational sac and an embryo with a heart beat is seen outside of the uterus 3. Ectopic is highly likely if ANY adnexal mass distinct from the corpus luteum or a significant amount of free pelvic fluid is seen.31

slides 33-37 When ultrasound is not definitive, correlation of serum hCG levels is important. If the hCG is above the “discriminatory zone” of 1500 to 2000 mIU/ml IRP, a gestational sac should be visible on transvaginal ultrasound.4 The discriminatory zone varies by ultrasound machine and sonographer. If an intrauterine gestational sac is not visible by the time the hCG is at, or above, this threshold, the pregnancy has a high likelihood of being ectopic. When serum hCG is less than 1500 mIU/ml, and ultrasound findings are unclear serial quantitative hCG levels in combination with follow-up imaging are most useful. Repeat serum hCG should be drawn in 48 hours. Based on a study that followed 287 women presenting in early pregnancy with pain or bleeding, the minimum rise necessary for a viable pregnancy over this time period is 53 percent.32

— Chapter A: First Trimester Pregnancy Complications — 7 In some cases of ectopic pregnancy, a small fluid collection within the uterus can be mistaken for a true gestational sac. However, this pseudogestational sac lacks a surrounding echogenic ring of chorionic villi, a yolk sac or fetal pole. An unruptured corpus luteum cyst or may be mistaken for an ectopic gestational sac, and a ruptured corpus luteum cyst may produce free pelvic fluid suggesting ruptured ectopic pregnancy. Culdocentesis can be very helpful in differentiating the thin, pink fluid of a ruptured ovarian cyst which can be managed expectantly from the frank hemorrhage due to ruptured ectopic pregnancy, but improved use of ultrasound and highly sensitive hCG decreases the need for this procedure. The presence of ANY cul-de-sac fluid indicates ectopic pregnancy until proven otherwise. Slides 33, 34 and 36 show sonographic images of extrauterine mass, pseudosac and free pelvic fluid.

When hCG levels are not rising normally and ultrasound cannot confirm pregnancy location, a dilation and curretage (D&C) or manual vacuum aspiration may yield chorionic villi or a gestational sac 38 percent of the time.33 When this happens a failed intrauterine pregnancy is diagnosed and treatment for an ectopic pregnancy avoided. When suspicion for ectopic pregnancy is high but cannot be confirmed with noninvasive testing, laparoscopy can both confirm the diagnosis and accomplish treatment. slides 38-42 ECTOPIC PREGNANCY: MANAGEMENT With early diagnosis the management of ectopic pregnancy has firmly moved into the outpatient realm. Current treatment options favor medical and laparoscopic management34 with expectant management reserved for cases with a declining quantitative hCG < 1,00035 and open surgical management limited to cases of tubal rupture and hemoperitoneum. Surgical management via laparoscopy or open laparotomy can involve complete removal of the fallopian tube (salpingectomy) or efforts to remove the ectopic pregnancy and conserve the tube (salpingostomy). Ectopic pregnancies located in the tubal cornua, interstitial area or uterine cervix are exceedingly dangerous and difficult to treat. Table 6 shows indications for surgical management.

Table 6. Indications for Surgical Management of Ectopic Pregnancy

Unstable vital signs or signs of hemoperitoneum

Uncertain diagnosis

Advanced ectopic pregnancy (high hCG, large mass, cardiac activity)

Unreliable follow-up

Any contraindication to observation or methotrexate

Expectant or medical treatment are options in hemodynamically stable women who are carefully selected and informed according to the criteria in Tables 7 and 8.36,37,38 Human chorionic gonadotropin level is the best predictor of successful treatment with methotrexate. A systematic review of several studies showed that failures with single dose methotrexate occurred 3.7 percent of the time when hCG levels were below 5,000 mIU/ml vs. 14.3 percent when higher than this cut-off. Thus, methotrexate use is used only in special circumstances when hCG levels exceed 5,000 mIU/ml.39

8 — — Chapter A: First Trimester Pregnancy Complications Table 7. Criteria for Expectant Management Include:35,36,37,38

Minimal pain or bleeding

Patient reliable for follow-up

No evidence for tubal rupture

Starting hCG level less than 1000 mlU/ml and falling

Ectopic or adnexal mass less than three centimeters, or not detected

No embryonic heartbeat

Table 8. Criteria for Medical Management of Ectopic Pregnancy With Methotrexate35,36,37,38

Stable vital signs and low level of symptomatology

No medical contraindication for methotrexate therapy (normal liver enzymes, complete blood count and platelet count)

Unruptured ectopic pregnancy

Absence of embryonic cardiac activity

Ectopic mass four centimeters or less

Starting hCG levels less than 5000 to 10,000 mlU/ml

Expectant management is used most often when the actual location of the pregnancy cannot be determined. Medical management with methotrexate, a folic acid antagonist, is appropriate for properly selected patients and has been shown in randomized trials to be safe and effective; it also can be less costly and result in equal or better subsequent fertility than conservative surgical treatment.34,40,41,42 As with expectant treatment, patient selection and close follow-up are key to safety and success. Single dosage intramuscular regimens are commonly calculated at one mg/kg or 50 mg/m2. Protocols for single and multiple dose regimens are shown in Table 9.43 Serum hCG testing is performed on the fourth and seventh post-treatment days and then followed weekly until the level reaches 5 mIU/ml, which may take three to four weeks. The hCG initially rises slightly, but should fall 15 percent between days four and seven; if not, the dosage should be repeated or surgical therapy performed. The methotrexate dosage should be repeated no more than once before surgical consultation is obtained. Because some patients managed expectantly or with methotrexate will eventually require surgery, prompt consultation is essential for the non-surgeon.

— Chapter A: First Trimester Pregnancy Complications — 9 Table 9. Single and Multiple Dose Methotrexate Regimens for Treatment of Ectopic Pregnancy Supplement to: Barnhart KT. Ectopic Pregnancy. N Engl J Med 2009;361:379-87.

Table 9. Treament Protocols for Ectopic Pregnancy Using Methotrexate (MTX).

Treament Single Dose (46) Two-Dose (47) Multi-dose (48) Pretreatment, rule hCG, creatinine, liver hCG, creatinine, liver hCG, creatinine, liver out spontaneous function, CBC w/diff function, CBC w/diff function, CBC w/diff abortion

Day #1 Check hCG value, Check hCG value, Check hCG value, Administer Administer first dose of Administer first dose of first dose of MTX 1 mg/kg IM MTX 50 mg/m2 IM MTX 50 mg/m2 IM Followed by Leucovorin 0.1 mg/kg IM on Day 2 Check hCG on day 2

Day #4 Check hCG value Check hCG value, Administer second dose of Administer second dose MTX (day 3) and Leucovorin of MTX 50 mg/m2 IM (day 4) on and respectively. Check hCG on day 4

Day #7 Check hCG value for Check hCG value for 15 % Continue administering doses 15 % decrease between decrease between days of MTX and Leucovorin (Ie days 4 and 7. 4 and 7. course 3 day 5 and 6 and course 4 day 7 and 8) until If > 15 % fall, check If > 15 % fall, check hCG hCG values have declined by hCG weekly until not weekly until not detect- 15 %. Do not exceed 4 courses detectable in serum. able in serum. If < 15 % fall, administer If < 15 % fall, administer If > 15 % decline, check hCG second dose MTX, third dose MTX, 50 mg/ weekly until not detectable in 50 mg/m2 IM m2 IM serum.

Day #11 Check hCG value for 15 % decrease between days 7 and 11. If > 15 % decline, check hCG weekly until not detectable in serum. If < 15 % fall, administer fourth dose MTX, 50 mg/ m2 IM

Weekly If follow-up hCG value If follow-up hCG value If follow-up hCG value surveillance plateau or rise, consider plateau or rise, consider plateau or rise, consider surgi- surgical intervention or surgical intervention or cal intervention or repeat dose repeat dose of MTX as repeat dose of MTX as of MTX as additional therapy. additional therapy. additional therapy.

10 — — Chapter A: First Trimester Pregnancy Complications slides 43-46 GESTATIONAL TROPHOBLASTIC DISEASE: PATHOPHYSIOLOGY AND RISK FACTORS SLIDES Gestational trophoblastic disease, or molar disease is an occasional cause of first trimester bleeding in the U.S. (1:1000 to 1:1500) but is more common in Southeast Asia.

Complete mole consists of placental proliferation in the absence of a fetus. Risk factors include extremes of age and previous molar pregnancy. The placental villi are swollen and often resemble bunches of grapes. Most complete moles have a 46 XX chromosomal composition, all derived from paternal sources Mole recurrence may progress to metastatic choriocarcinoma. Partial mole is a molar placenta occurring together with a fetus, which is usually non-viable. Genetic testing usually reveals triploidy (69 XXY). Partial mole is less common than a complete mole, and carries a lower risk of recurrence.

Gestational Trophoblastic Disease: Signs, Symptoms and Diagnosis The signs and symptoms of gestational trophoblastic disease are shown in Table 10.

Table 10. Signs and Symptoms of Trophoblastic Disease

Uterus larger than expected for gestational age

Absent fetal heart beat

Higher than expected hCG levels

Hyperemesis, pregnancy-induced hypertension at an early gestational age, and/or thyrotoxicosis

Ovarian enlargement, caused by theca-lutein cysts resulting from ovarian hyperstimulation by the high hCG levels

Vaginal bleeding in the first or early second trimester, which is often dark, and may cause anemia

Grape-like vesicles are passed in cases that progress into the second trimester

In cases of complete mole, ultrasound diagnosis is suggestive when there are multiple vesicular spaces within the uterus and there is no fetus. Enlarged cystic ovaries are common. While this diagnosis is usually quite straight forward in the second trimester it can be very difficult to make in the first trimester. Especially in the case of a partial mole that has an embryo.

GESTATIONAL TROPHOBLASTIC DISEASE: TREATMENT Prompt evacuation of the uterus is the primary treatment. After evacuation of a complete mole, all patients should have serial monitoring of hCG for six months to one year with contraception.44 If the hCG plateaus or rises, then recurrence must be assumed, investigated and treated with chemotherapy (methotrexate). Because of the relative rarity of the disease and the many possible complications, consultation is recommended. Theca-lutein ovarian cysts require no treatment and will resolve after evacuation of the molar tissue. About 20 percent of women with a complete mole will experience recurrence in the form of mole that invades the myometrium or becomes aggressively metastatic.

— Chapter A: First Trimester Pregnancy Complications — 11 GRIEF AND PSYCHOLOGICAL MANAGEMENT OF EARLY PREGNANCY LOSS SLIDES slides 47,48 Miscarriage represents a major loss to the pregnant woman and her family. The grief reaction that often follows is similar in intensity to that experienced after other major losses, though women experience and describe it in varied ways.45 Although healing will occur, the time to recovery also varies. The feelings of loss tend to be strongest in the first six months after the event,46 but they can be persistent and pervasive enough to cause long-term symptoms or even affect the patient’s next pregnancy.47 Women at risk for a stronger grief reaction include those who experienced a missed abortion, those with loss at a later gestational age, those with a longer time to conception of their next pregnancy, and those with a critical self-perception.47,48 Partners also experience grief with pregnancy loss. Because men are often a primary social support for patients and attend up to 20 percent of post-loss visits,49 it is important for the healthcare provider to include them in the care plan. Available evidence suggests that although the vast majority of women desire support from their health care provider, many don’t receive the quantity or quality of support they desire.45 The types of interventions that are most effective in managing psychologic symptoms are still uncertain,50 but the following approaches may be practical ways to mitigate the normal grief that follows early pregnancy loss.51

Acknowledge and attempt to dispel guilt. Many women believe that some action on their part caused or contributed to the miscarriage. This guilt may revolve around sexual activity, food, minor trauma, physical activity or emotional stress. Women whose losses can be ascribed to a definite cause have lower levels of anxiety and grief.52,53 Therefore, evaluation of available tissue for chromosomal anomalies is recommended when possible. Even when a definitive cause cannot be ascertained, reassurance that the patient did nothing to cause the loss is appropriate. This reassurance may need to be repeated several times. Women should be counseled that genetic or developmental errors probably occurred early in the pregnancy, and there was no possibility of this pregnancy progressing to produce a live baby. The post-loss follow-up visit is not the time to focus on modifiable risk factors that may have contributed to the loss (ie, alcohol or tobacco use). Addressing these issues prior to future pregnancies is certainly indicated, but is better done after the acute trauma of loss fades. The patient’s religious belief system may be called on during this counseling.

Acknowledge and legitimize grief. Allowing patients to discuss their emotions surrounding their loss may be the most important aspect of psychologic care. One study suggests that women who had a medical follow-up visit at which they were not provided an opportunity to discuss their feelings actually had more anxiety and depression than those who had no follow-up at all.45 Patients and their partners should be allowed to cry or feel sad. Minimizing their feelings will isolate them and decrease the provider’s credibility. Legitimize their feelings by confirming that miscarriage is the death of a baby. Comments such as “you can try again” or “at least it happened early” are inappropriate. Simple measures that validate grief should not be underestimated. Listening to the patient, holding her hand, or telling her how sad you feel for her can help her through this traumatic period. The patient should be seen within one to two weeks in the office, or called on the phone a few days after the miscarriage.

Reassure about the future. Grief will fade with time. Most patients have an excellent chance of a subsequent normal pregnancy. With fewer than three miscarriages, the risk of miscarriage in future pregnancies is no greater than usual. It is important to explain that the next pregnancy will not need to be managed differently because of the miscarriage. This is an excellent time to encourage the initiation of a prenatal vitamin.

12 — — Chapter A: First Trimester Pregnancy Complications Counsel the patient how to tell family and friends of the miscarriage. If family members and friends knew about the pregnancy, a designated person may inform them of the loss. This allows them to express their sympathy and provide emotional support, and may avoid embarrassing encounters in which others assume the pregnancy is progressing uneventfully. If the pregnancy were a secret, then family and friends may puzzle over any external signs of grief or distress. A decision must be made whether to tell them. Informing other children in the family may also be difficult, however families often find comfort in allowing children to share in the grieving and remembering process.54 Parents should be encouraged to discuss the loss in honest and developmentally appropriate ways, just as they would the death of any other family member.

Warn patients of the anniversary phenomenon. A recurrence of grief feelings on their due date or the anniversary of the miscarriage may occur. This might also develop at the birth of a friend’s baby or during their own subsequent pregnancy.47 Posttraumatic stress disorder should be considered in women experiencing prolonged grieving, anxiety, or other symptoms that affect their general or reproductive functioning.

Include the partner in your psychological care. Partners often feel the pain of loss and should be included in counseling and decisions. Men’s reactions to pregnancy loss are more strongly influenced by the status of the marital relationship than are women’s.47 Offering couples counseling and including fathers in the healing process may speed resolution for both partners.55

Assess level of grief and adjust counseling accordingly. Many women are ambivalent or distressed by the pregnancy and may experience very mixed feelings or profound relief at the loss. A history of previous abortion, failed birth control, or rape may further complicate the emotional response. Allowing the patient to express her emotions in a supportive and non-judgmental atmosphere is always an appropriate intervention.

slide 49 RH PROPHYLAXIS AND FUTURE CONCEPTION AFTER PREGNANCY LOSS Several follow-up issues must be addressed after any type of pregnancy loss. Rh negative women who miscarry during the first trimester should receive 50 mcg of anti D immune globulin.56 Contraception should be discussed and started immediately, as all methods are equally safe immediately following spontaneous abortion or ectopic pregnancy. There is no good evidence suggesting an ideal interpregnancy interval.57 Folic acid supplementation prior to future conception attempts substantially reduces the risk of neural tube defects.58 slides 50, 51 SUMMARY First trimester pregnancy complications are common and the differential diagnosis includes life- threatening conditions such as ectopic pregnancy. Knowledge and application of discriminatory criteria can significantly aid in distinguishing normal early pregnancy from miscarriage and ectopic pregnancy. While surgical treatment is the mainstay of ectopic pregnancy treatment, medical and expectant treatments are possible in properly selected cases. In incomplete miscarriage, nonsurgical treatments have a high likelihood of success but depend on diagnosis; in embryonic demise or anembryonic pregnancy, misoprostol or surgical treatment are considerably more effective than expectant treatment. Because there is a lack of clear superiority of expectant versus surgical management of miscarriage, the woman’s preference should play a dominant role in decision making.59

— Chapter A: First Trimester Pregnancy Complications — 13 When the choice is made to treat early pregnancy failure by other than expectant means, vaginal misoprostol is highly efficacious, safe and well-accepted by women, with fewer gastrointestinal side-effects than the oral route. Evidence does not support the use of antibiotics in all women with incomplete abortion. After any type of first trimester pregnancy loss, Rh negative women should receive 50mcg of anti D immune globulin. Acknowledgement of grief, empathy and reassurance are useful techniques in counseling women after miscarriage. Slide 51 shows an algorithm for the diagnostic approach to the patient with a positive pregnancy test and pain or bleeding.

OPTIONAL SECTION slides 52, 53 Surgical Management of Miscarriage: (Dilation and Curettage and Manual Vacuum Aspiration) The majority of first trimester miscarriages occur completely and spontaneously without intervention, and when intervention is selected, medical management is highly effective. Uterine aspiration by electric suction or manual vacuum aspiration may be indicated when: 1. Heavy bleeding is present (greater than a pad an hour). slide 53 2. Patient is clinically stable (no bleeding or cramping), but pregnancy loss is demonstrated con- clusively and the patient prefers intervention to expectant management to await for spontaneous completion. 3. Ectopic pregnancy needs to be ruled out. In certain situations a clinical distinction cannot be made between an ectopic and an intrauterine pregnancy. If tissue from a D&C contains chorionic villi, the pregnancy was intrauterine. Very rarely, an intrauterine and an ectopic pregnancy (heterotopic pregnancy) may coexist, creating a confusing and dangerous clinical situation.

Contraindications to Uterine Aspiration 1. Medical contraindications are rare but include active pelvic infection and coagulopathy. 2. Pregnancy loss is not proven to the patient’s satisfaction, the physician’s satisfaction, or both. 3. The patient prefers to await spontaneous completion for any reason (religious beliefs, cost, desire to avoid surgical procedures, etc.).

Uterine aspiration is not appropriate if the spontaneous abortion appears to be complete by the slide 54 following criteria: • The uterus is small and firm. • Scant or no bleeding is occurring. • Tissue has been passed and is available for inspection and appears complete. • The patient is reliable in follow-up. • Ultrasound examination (preferably transvaginal) shows an empty uterus.

slide 55

14 — — Chapter A: First Trimester Pregnancy Complications How to Perform a Uterine Aspiration (Suction Dilation and Curettage) slide 55 Under Local Anesthesia 1. Place an intravenous (IV) line if patient is bleeding heavily or if IV medications are to be used. 2. A hematocrit or hemoglobin and an Rh test should be obtained. A white blood count, prothrombin time, partial thromboplastin time, fibrin split products, and blood type and screen may be obtained depending on clinical circumstances (e.g. heavy bleeding, missed abortion). 3. Sedation and analgesia should be administered. Two to five mg of IV midazolam (VersedR) and, 50 to 100 mcg of IV FentanylR are commonly used. Alternatively, 25 to 50 mg of meperi- dine (Demerol) and/or five to 10 mg diazepam (Valium) may be used. In many situations, the patient’s partner or another support person may sit with her during the procedure. 4. The size and position of the uterus should be identified by bimanual exam. If the fetal measurements and uterine size are greater than 14 weeks in size, then a dilation and extraction procedure is indicated which requires advanced training beyond that required for first trimester aspiration. If a procedure is required beyond 14 weeks consider adding 20 units of oxytocin to intravenous fluids. 5. The cervix should be exposed with a speculum. A medium Graves speculum usually suffices. The cervix and posterior fornix are cleansed with an antiseptic solution. The anterior lip of the cervix is then grasped with a single toothed tenaculum. 6. A paracervical block can be achieved with 10 cc of two percent chloroprocaine (NesacaineR) slide 56 or 20 cc of 1 % lidocaine (XylocaineR) via a 20 gauge spinal needle. One fourth of the amount of the block is administered at 3:00, 5:00, 7:00, and 9:00 or one half the amount of the block at 4:00 and 8:00 where the cervix meets the vagina. A superficial wheal is raised and the syringe is aspirated before injecting to avoid intravascular injection. Several variants of the paracervical block exist, and all are equally satisfactory. slide 57 7. If the cervix is closed, or insufficiently dilated to easily admit the required suction curette, it can be progressively dilated using cervical dilators. Dilation should occur to the number of mm that is equivalent to the estimated gestatinal age in weeks or one mm less ( e.g, dilate to 9 or 10 mm to aspirate a ten week missed abortion) Control is indicated for this portion of the procedure, as dilators and uterine sounds cause the largest number of uterine perforations. If the patient is clinically stable, overnight dilation with laminaria is an option. Another means of dilation that has had success, but not FDA approved, is the oral administration of misoprostol (CytotecR) 600 ucg or vaginal administration of 400 ucg two to four hours before the procedure. 8. The uterus is carefully sounded to determine the axis of the cervix and uterine cavity to guide slide 58 further instrumentation. If the os is open, a ring forceps or blunt curette can be used as a sound and any loose tissue encountered can be removed. 9. The suction curette should be equivalent to the size of the uterus in weeks (e.g. a # 10 curette for a 10 weeks’ sized uterus) is appropriate. A curved curette is used if the uterus is anteflexed or retroflexed. A straight curette may be used if the uterus is midposition. The suction curette is inserted along the previously determined axis of the uterus, until slight resistance is felt, while exerting slight traction on the tenaculum to stabilize the cervix and straighten out the cervico-vaginal angle. The curette should never be forced after passing the internal os, as perforation is the most serious potential complication of the procedure.

— Chapter A: First Trimester Pregnancy Complications — 15 10. Once the curette is in place, the suction hosing is attached and the suction machine turned slide 59 on. The suction valve on the handle of the hose is then closed. Sixty cm of mercury (Hg) or greater must be achieved for adequate suction. 11. With the suction on, the curette is rotated several times in one direction, then several times in the other direction, with slight in-and-out motion. Most of the pressure should be maintained lateral and forceful jabbing at the uterine fundus avoided, since perforation is a risk. The amount and nature of tissue that appears in the plastic curette should be carefully observed. Products of conception often appear tan or grey, admixed with blood and clots. Yellowish fluid may be noted. The curette is withdrawn slowly, avoiding the vaginal side wall while the suction is operating. 12. The suction and rotation sequence can be repeated after inserting the curette into the uterus again.

13. An alternative to electric suction curettage is manual vacuum aspiration, or MVA. This is slides 60, 61 accomplished with a simple handheld plastic syringe which generates its own suction mechanically. This device is inexpensive, easy to use, and requires no electricity. It is particularly appropriate for completions of very early gestations (eg: under eight to 10 weeks menstrual age.). It may be used in the office setting where a suction machine is not accessible. It is also appropriate in developing countries where electricity is not available. 14. A light, sharp curettage of the uterus may be done to determine that it is indeed empty, fol- slides 62-67 lowed by one more pass of the suction curette. This is no longer routinely indicated due to the increased pain and increasing use of postprocedure vaginal ultrasound to confirm completion in association with examination of tissue. 15. After examination of the tissue it should be sent to pathology for confirmation of diagnosis. To confirm an intrauterine pregnancy, chorionic villi must be identified. 16. After the uterine aspiration is completed, the patient should be monitored for excessive bleeding. Misoprostol can be given by the rectal, buccal or sublingual route in a dose of 400 to 800 micrograms. Oxytocics can be given as appropriate (Oxytocin 20 units given in a liter of IV fluid or 10 units intramuscular or MethergineR 0.2 mg IM or orally (PO). Transfusions are rarely required. slide 68 17. If the patient is Rh negative, 50 mcg (mini dose) of Rh immune globulin should be given.56 18. Doxycycline 100 mg po bid for three days should be routinely given after uterine aspiration to decrease the likelihood of endometritis.

COMPLICATIONS OF UTERINE ASPIRATION (SUCTION D AND C) slide 69 Complications of uterine aspiration can occur, as with any surgical procedure. Careful performance of the procedure, consultation with more experienced physicians when needed, and a high index of suspicion for identifying complications may prevent complications from occurring. 1. Perforation — Perforation occurs when an instrument passes through the uterine wall. The slide 70 diagnosis is usually apparent when a sound or dilator passes through the cervix to a significantly greater depth than expected. Occasionally, a suction curette or a sharp curette will draw maternal abdominal contents such as omentum or bowel out through the cervix. Heavy bleeding, signs of peritonitis, or evidence of intra-abdominal bleeding may also help identify perforation. If perforation occurs with a blunt instrument such as a sound, and if the D&C has been completed, then observation alone for a minimum of two hours may suffice. If perforation has occurred with a sharp instrument such as a curette or with a suction curette, laparoscopy or

16 — — Chapter A: First Trimester Pregnancy Complications laparotomy may be indicated. If the uterine aspiration has not been completed at the time the perforation is identified, it may be completed under either ultrasonic or laparoscopic guidance. Broad-spectrum antibiotics such as a cephalosporin should be considered for any perforation. 2. Incomplete evacuation — Incomplete evacuation is identified by continued bleeding and cramping after the procedure, or ultrasound evidence of retained tissue or endometritis, and may be managed by repeating the procedure. Ultrasonic guidance or general anesthesia is often helpful. Antibiotics are recommended if the second procedure occurs more than a few hours after the first. Oxytocics also may be helpful including IV oxytocin, methylergonovine given IM or orally, or prostaglandin given by various routes. 3. Bleeding — The differential diagnosis of bleeding includes perforation, incomplete evacuation with retained tissue, cervical or uterine injury, or a bleeding disorder. Methylergonovine (MethergineR) 0.2 mg four times a day for two days is commonly given to patients who may have more than average bleeding during and after a procedure. An alternative is misoprostol (CytotecR) 200 ucg four times a day for two days. This drug is not FDA approved for this indication, but efficacious in practice due to its powerful uterotonic effect.25 4. Infection — Infection may be referred to as septic abortion, endometritis, paraendometritis or pelvic peritonitis. It is diagnosed by fever, uterine and parauterine tenderness, peritonitis, and an elevated leukocyte count. The treatment is antibiotics. For ill patients who require hospitalization, an intravenous cephalosporin or triple antibiotics (ampicillin, gentamycin, and clindamycin or metronidazole) may be required. Less ill patients may be treated as outpatients. Clear guidelines for antibiotic regimens are lacking. When tissue is found to be retained, repeating the uterine evacuation may be necessary. Oxytocics should be given as described in item number two above. Rarely, in very ill patients, hospitalization and hysterectomy may be necessary. 5. Late Sequelae — Intrauterine synechiae (Asherman’s syndrome) is often discussed but rarely seen. It is most likely when a suction D&C is performed in the presence of infection, a prolonged missed abortion, or postpartum. Incompetent cervix may rarely occur due to cervical injury. The most common late sequelae to suction D&C are depression and related psychological reactions to the loss of the pregnancy.

Algorithm: Approach to the patient with first trimester pain or bleeding

— Chapter A: First Trimester Pregnancy Complications — 17 Patient Presents with Pain or Bleeding and Positive Urine hCG N Resuscitation, surgical PRESUME Hemodynamically evaluation ECTOPIC stable? Expectant Y management

N Counsel Cervix INEVITABLE Medical patient on management Closed? SAB options:

Y Uterine aspiration US immediately N available?

Y Normal Serial hCG hCG rise? N US N Diagnostic ? Y

Y Pelvic mass, fluid in cul-de-sac, or Embryo with Watchful Ultrasound with extrauterine heartbeat cardiac activity waiting, PRESUME ECTOPIC diagnostic findings: Plan routine VIABLE UP f/u US

Characteristic Embryo (>5 mm) without Indication for Y Resuscitation surgical Surgical snowstorm pattern heart beat orSac (>20 mm) managment? evaluation MOLAR without fetal pole PREGNANCY FAILED PREGNANCY

N Counsel patient on options: Methotrexate Indication for Y Uterine Medical medical and close Aspiration management managment? follow-up Expectant N Management and follow-up

18 — — Chapter A: First Trimester Pregnancy Complications SORT: KEY RECOMMENDATIONS FOR PRACTICE Clinical Recommendation Evidence Rating References In discriminating normal from failing pregnancy, A normal preg- C 10 nancy should exhibit a gestational sac when hCG reaches 1500 to 2000 mIU/mL, a yolk sac when the gestational sac is ten mm in diameter and cardiac motion when the embryonic crown-rump length is 5 mm or greater.

Success of treatment for miscarriage depends on diagnosis. A 23, 24, 25 When the woman has an incomplete miscarriage, nonsurgical treatments have a high likelihood of success. When the woman has an embryonic demise or anembryonic pregnancy, misoprostol or surgical treatment for considerably more effective than expectant treatment.

There is a lack of clear supperiority of expectant versus surgical A 59 management of miscarriage. Therefore, the woman’ preference should play a dominant role in decision making.

When the choice is made to treat early pregnancy failure by other A 23, 24 than expectant means, vaginal misoprostol is highly efficacious, safe and well-accepted by women, with fewer gastrointestinal side-effects than the oral route.

Evidence does not support the use of antibiotics in all women A 27 with incomplete abortion.

After any type of first trimester pregnancy loss. Rh negative C 56 women should receive 50 mcg of anti D immune globulin.

Acknowledgement of grief, empathy and reassurance are useful C 51 techniques in counseling women after miscarriage. A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system: http://www.aafp.org/afpsort.xml.

— Chapter A: First Trimester Pregnancy Complications — 19 REFERENCES 1. Wilcox AJ, Weinberg CR, O’Connor JF. et.al. Incidence 17. Creinin MD, Harwood B, Guido RS, et al. Endometrial of early pregnancy loss N Engl J Med 319:189-194, thickness after misoprostol use for early pregnancy 1988. failure. I J Gynaecol Obstet. 2004;86:22-26. 2. Cole LA, Sutton-Riley JM, Khanlian SA, Borkovskaya 18. Bennett GL, Bromley B, Lieberman E, Benacerraf M, Rayburn BB, Rayburn WF. Sensitivity of over-the- BR. Subchorionic Hemorrhage in First-Trimester counter pregnancy tests: comparison of utility and Pregnancies: Prediction of Pregnancy Outcome with marketing messages. J Am Pharm Assoc. 2005 Sonography. Radiology 1996;200:803-806 Sep-Oct;45(5):608-15. 19. Hasan R, Baird DD, Herring AH, et al. Association 3. Lichtenberg ES. The behavior of Beta-hCG levels between first-trimester vaginal bleeding and miscar- before, during, and after early induced abortion. 2lst riage. Obstet Gynecol 2009;114:860-7. (Level II) Annual NAF Post-Graduate Seminar May 4, 1997 20. Geyman JP, Oliver LM, Sullivan SD. Expectant, medical 4. Barnhart KT. Ectopic pregnancy. NEJM or surgical treatment of spontaneous abortion in first 2009;361:379-87 trimester of pregnancy? A pooled quantitative literature 5. Seeber BE, Barnhardt KT Suspected Ectopic evaluation. J Am Board Fam Pract 1999;12:55-64. (Level 11-2) Pregnancy. Obstet Gynecol 2006:107:399-413 6. Banerjee S, Aslam N, Woelfer B, Lawrence A, Elson J, 21. Nielson S, Hablin M. Expectant management of first-tri- Jurkovic D. Expectant management of early pregnan- mester spontaneous abortion. The Lancet, 14 January, cies of unknown location: a prospective evaluation of 1995, Volume 345(8942) pp 84-86. (Level I) methods to predict spontaneous resolution of preg- 22. Luise C, Jermy K, May C, Costello G, Collins WP, nancy. BJOG 108:158-163, 2001. Bourne TH. Outcome of expectant management of 7. El Bishry G, Ganta S. The role of single serum proges- spontaneous first trimester miscarriage: Observational terone measurement in conjunction with bhCGin the study BMJ 2002;324;873-875 (LOE 3 observational management of suspected ectopic pregnancy. study. J Obstet Gynaecol. 28(4):413-7, 2008. 23. Zhang J, Giles JM, Barnhart K; et al. A comparison of 8. Gracia CR, Barnhart KT. Diagnosing ectopic preg- medical management with misoprostol and surgical nancy: decision analysis comparing six strategies. management for early pregnancy failure. N Engl J Med 2005;353:761-769. [LOE 1, RCT] Obstet Gynecol. 97:464-70, 2001. [LOE II-2] 9. Laing FC, Frates MC. Ultrasound evaluation dring 24. Bagratee JS, Khullar V, Regan L, et al. A randomized the first trimester of pregnancy. In: Callen PW ed. controlled trial comparing medical and expectant man- Ultrasonography in Obstetrics and Gynecology 4th ed. agement of first trimester miscarriage. Hum Reprod 2000 W.B. Saunders Co. Philadelphia 2004;19:266-271. [LOE 1, RCT] 10. Paspulati RM, Bhatt S, Nour S. Sonographic evaluation 25. Weeks A, Alia G, Blum J, et al. A randomized trial of misoprostol compared with manual vacuum aspiration of first-trimester bleeding. Radiol Clin North Am. 2004 Mar;42(2):297-314. for incomplete abortion. Obstet Gynecol 2005;106:540- 547. [LOE 1, RCT] 11. Kadar N, Bohrer M, Kemmann E, Shelden R. The discriminatory human chorionic gonadotropin zone for 26. Winikoff B. Pregnancy failure and misoprostol--time for endovaginal sonography: A prospective, randomized a change. N Engl J Med 2005;353:834-836. [LOE 3, study. Fertil Steril 1994;6l:l0l6-20. opinion] 12. Whitworth M, Bricker L, Neilson JP, Dowswell T. 27. May W, Gülmezoglu AM, Ba-Thike K. Antibiotics Ultrasound for fetal assessment in early pregnancy. for incomplete abortion. Cochrane Database of Cochrane Database of Systematic Reviews 2010, Systematic Reviews 2007, Issue 4. Art. No.: CD001779. Issue 4. Art. No.: CD007058. DOI: 10.1002/14651858. DOI: 10.1002/14651858.CD001779.pub2. CD007058.pub2 (Level I) 28. Fjerstad M, Trussell J, Sivin I, Lichtenberg ES, Cullins V. 13. Creinin MD, Schwartz JL, Guido RS, Pymar HC. Early Rates of Serious Infection after Changes in Regimens pregnancy failure--current management concepts. for Medical Abortion N Engl J Med 2009;361:145-51. Obstet Gynecol Surv. 2001 Feb;56(2):105-13. 29. Buss L, Tolstrup J, Munk C, Bergholt T, et al. 14. Chen BA, Creinin MD. Contemporary management Spontaneous abortion: A prospective cohort study of younger women from the general population in of early pregnancy failure. Clin Obstet Gynecol. 2007 Mar;50(1):67-88. Denmark. Validation, occurrence and risk determi- nants. Acta Obstet Gynecol Scand 2006;85(4):467-75. 15. Goddign M, Leschot NJ. Genetic Aspects of (Level II) Miscarriage. Bailliere’s Clinical Obstetrics and Gynaecology 2000;14(5):855-865, 30. Grimes D, Schulz K, Stanwood N. Immediate post- abortal insertion of intrauterine devices (Cochrane 16. Smith KE, Buyalos RP. The profound impact of patient Review). In: The Cochrane Library, Issue 3, 2009. age on pregnancy outcome after early detection of fetal Oxford: Update Software. (Level I) cardiac activity. Fertil Steril 1996;65:35-40. (Level III)

20 — — Chapter A: First Trimester Pregnancy Complications 31. Sawyer E,Jurkovic D. Ultrasonography in the diagnosis miscarriage: a randomized study. Acta Obstet Gynecol and management of abnormal early pregnancy. Clin Scand. 2006;85(3):330-5. Obstet Gynecol. 2007 Mar;50(1):31-54. (Level III) 49. Revak-Lutz RJ, Kellner KR Paternal involvement after 32. Barnhart KT, Sammel MD, Rinaudo PF, Zhou L, perinatal death. J Perinatol. 1994 Nov-Dec;14(6):442-5. Hummel AC, Guo W. Symptomatic patients with an 50. Stratton K, Lloyd L Hospital-based interventions at and early viable intrauterine pregnancy; hCG curves rede- following miscarriage: literature to inform a research- fined. 2004;104:50–5. (Level II) Obstet Gynecol practice initiative. Aust N Z J Obstet Gynaecol. 2008 33. Barnhart KT, Katz I, Hummel A, Gracia CR. Presumed Feb;48(1):5-11. Review. Diagnosis of Ectopic Pregnancy. Obstetrics & 51. DeFrain J, MilIspaugh E, Xiaolin X. The Psychosocial Gynecology 2002;100(3):505-510. Effects of Miscarriage: Implications for Health 34. Hajenius PJ, Mol BWJ, Bossuyt PMM, Ankum WM, Van Professionals. Fam Syst & Health,14;1996:331-347 der Veen F. Interventions for tubal ectopic pregnancy 52. Nikcevic AV, Tunkel SA, Kuczmierczyk AR, Nicolaides Cochrane Database of Systematic Reviews. 3, 2007 KH Investigation of the cause of miscarriage and its 35. Cohen MA, Sauer MV. Expectant management of influence on women’s psychological distress. Br J ectopic pregnancy. Clinical obstetrics and gynecology Obstet Gynaecol. 1999 Aug;106(8):808-13. 1999;42(1):48-54. (Level III) 53. Nikcevic AV, Kuczmierczyk AR, Nicolaides KH The 36. Mashiach S, Carp JH, Serr DM: Nonoperative manage- influence of medical and psychological interventions ment of ectopic pregnancy. J Reprod Med 27:127, 1982. on women’s distress after miscarriage. J Psychosom (Level III) Res. 2007 Sep;63(3):283-90 37. Adoni A, Milwidsky A, Hurwitz A, Palti Z: Declining 54. Wilson RE Parents’ support of their other children after b-hCG levels: An indicator for expectant approach in a miscarriage or perinatal death. Early Hum Dev. 2001 ectopic pregnancy. Int J Fertil 1986;31:40. (Level III) Mar;61(2):55-65 38. Garcia Al, Aubert JM, Sarna J, Josimovich JB: 55. Swanson KM, Chen HT, Graham JC, Wojnar DM, Expectant management of presumed ectopic pregnan- Petras A. Resolution of depression and grief during the cies. Fertil Steril 1987;48:395-400. (Level III) first year after miscarriage: a randomized controlled 39. Menon S, Colins J, Barnhart KT. Establishing a human clinical trial of couples-focused interventions. chorionic gonadotropin cutoff to guide methotrexate J Womens Health (Larchmt). 2009 Aug;18(8):1245-57 treatment of ectopic pregnancy: a systematic review. 56. ACOG Practice Bulletin: Prevention of Rh D Fertil Steril 2007;87:481-4. [LOE III] Alloimmunization. Number 4, May 1999 40. Medical management of ectopic pregnancy. ACOG 57. Vlaanderen W, Fabriek LM, van Tuyll van Serooskerken practice bulletin No. 94. American College of C. Abortion risk and pregnancy interval, Acta Obstet Obstetricians and Gynecologists. Obstet Gynecol Gynecol Scand. 1988;67(2):139-40. 2008;111:1479-85. (Level III) 58. Lumley J, Watson L, Watson M, Bower C. 41. Stovall TG, Ling FW. Single-dose methotrexate: Periconceptional supplementation with folate and/ An expanded clinical trial. Am J Obstet Gynecol or multivitamins for preventing neural tube defects. 1993;168:1759-65. (Level III) Cochrane Database of Systematic Reviews 2009, 42. Lipscomb, GH, McCord ML, Stovall TG et.al. Predictors Issue 3. of success of methotrexate treatment in women with 59. Nanda K, Peloggia A, Grimes D, Lopez L, Nanda tubal ectopic pregnancies. N Engl J Med 1999;341:1974- G. Expectant care versus surgical treatment for 8. (Level III) miscarriage. Cochrane Database of Systematic 43. Supplement to: Barnhart KT. Ectopic pregnancy. Reviews 2006, Issue 2. Art. No.: CD003518. DOI: 10.1002/14651858.CD003518.pub2. N Engl J Med 2009;361:379-87.” .(Level III) 44. Berkowitz RS, Goldstein DP,. Molar Pregnancy. NEJM 2009;360(16):1639-1645 45. Nikcevic AV, Tunkel SA, Nicolaides KH.Psychological outcomes following missed abortions and provision of follow-up care. Ultrasound Obstet Gynecol. 1998 Feb;11(2):123-8. 46. Brier N.Grief following miscarriage: a comprehensive review of the literature. J Womens Health (Larchmt). 2008 Apr;17(3):451-64. Review. 47. Franche RL.Psychologic and obstetric predictors of couples’ grief during pregnancy after miscarriage or perinatal death. Obstet Gynecol. 2001 Apr;97(4):597-602 48. Adolfsson A, Berterö C, Larsson PG. Effect of a structured follow-up visit to a midwife on women with early

— Chapter A: First Trimester Pregnancy Complications — 21 Chapter B Medical Complications of Pregnancy slide 1 Larry Leeman MD, MPH Lee Dresang MD Pat Fontaine MD, MS

Published May 2006

slide 2 OBJECTIVES After completing this chapter, participants will be able to: 1. Describe the following medical conditions that can lead to significant morbidity and maternal mortality during the peripartum period: a. Gestational hypertension, preeclampsia, eclampsia, and HELLP syndrome b. Acute fatty liver of pregnancy c. Peripartum cardiomyopathy d. Deep vein thrombosis and pulmonary embolism 2. Formulate a diagnosis and management plan for each of the above.

INTRODUCTION The presence of a fetus complicates many medical problems through complex interactions between the mother, the disease, and the treatment. Understanding these interactions is crucial for optimizing outcomes for both mother and baby. The mother is the first priority in any medical emergency, since the fetus is dependent on her for physiologic support. In managing an eclamptic seizure or pulmonary embolism, for example, every effort is directed toward supporting maternal vital functions, using any necessary critical care interventions. Concern for the fetus is demonstrated by treating the mother with medications that lack toxic or teratogenic effects, and by choosing tests that limit direct fetal x-ray exposure. This chapter focuses on four potentially life-threatening medical complications: hypertensive disorders, acute fatty liver of pregnancy (AFLP), peripartum cardiomyopathy (PPCM), and thromboembolic disease. The hypertensive disorders are the most common medical complications of pregnancy, while AFLP and PPCM are uncommon disorders unique to pregnancy that cause significant morbidity and mortality. Thromboembolic disease is the leading cause of maternal mortality in more developed countries.

HYPERTENSIVE DISORDERS OF PREGNANCY slide 3 In the United States, hypertensive disorders represent the most common medical complication of pregnancy, affecting six to eight percent of gestations.1 As defined by the National High Blood Pressure Education in Pregnancy (NHBPEP) Working Group, hypertension in pregnancy may be chronic (occurring prior to 20 weeks gestation or persisting beyond 42 days post partum), may arise de novo during the pregnancy (gestational hypertension or preeclampsia), or may represent a superimposition of preeclampsia on chronic hypertension.1

— Chapter B: Medical Complications of Pregnancy — 1 CHRONIC HYPERTENSION Chronic hypertension is defined as an elevated blood pressure greater than 140/90 mm Hg on two slide 4 occasions prior to or during the first 20 weeks of pregnancy. Treatment of mild to moderate chronic hypertension in pregnancy has no proven fetal benefit, nor has it been shown to prevent preeclampsia.2-4 Excessively lowering the blood pressure may result in decreased placental perfusion and adverse perinatal outcomes.5 However, when the blood pressure is persistently greater than 150 to 180/100 to 110 mm Hg, pharmacologic treatment is indicated in order to prevent maternal end organ damage.1,4 A lower threshold is appropriate for treating women who already manifest target organ damage such as renal insufficiency and left ventricular hypertrophy.1

Methyldopa, labetalol, and nifedipine are the oral agents most commonly used for severe chronic hypertension in pregnancy. ACE inhibitors and angiotensin II receptor antagonists should not be used due to association with intrauterine growth restriction (IUGR), oligohydramnios, neonatal renal failure and death.4 The beta-blocker atenolol, has been associated with IUGR4, and thiazide diuretics can exacerbate the intravascular fluid depletion of preeclampsia if chronic hypertension becomes complicated by superimposed preeclampsia.

Women in active labor with uncontrolled severe chronic hypertension require treatment with intravenous labetalol or hydralazine in doses similar to those used for severe preeclampsia.

Women with chronic hypertension should be monitored carefully for the development of superimposed preeclampsia or IUGR.4 The development of proteinuria, a sudden increase in blood pressure in a woman whose hypertension has previously been well controlled, or development of the signs and symptoms of severe preeclampsia are diagnostic for superimposed preeclampsia. Fetal growth may be assessed by serial fundal height measurements supplemented by ultrasounds every three to four weeks starting at 28 to 32 weeks of gestation.4

GESTATIONAL HYPERTENSION The NHBPEP Working Group has recommended that “gestational hypertension” replace the term slide 5 “pregnancy-induced hypertension.”1 Pregnant women who develop hypertension after 20 weeks and do not have significant, preeclampsia-level proteinuria should be diagnosed with gestational hypertension. Gestational hypertension is a provisional diagnosis used for a heterogeneous group of women including 1) those who will eventually develop proteinuria during the pregnancy and be diagnosed with preeclampsia, 2) those who will have persistent hypertension after 12 weeks postpartum and be diagnosed with chronic hypertension, and 3) those who do not develop preeclampsia and whose blood pressures normalize postpartum. Women in this last group are ultimately diagnosed as having had “transient hypertension of pregnancy.”

Gestational hypertension is not a benign category. Approximately 50 percent of women diagnosed with gestational hypertension between 24 to 35 weeks ultimately develop preeclampsia.6 Expectant management of gestational hypertension can reduce the increased cesarean delivery rate that occurs with inductions.7 If the blood pressure progresses to the severe range (systolic greater than 160 mm Hg or diastolic greater than 110 mm Hg), then management similar to a severe preeclamptic is required even if the patient does not have proteinuria, because women with severe gestational hypertension have worse perinatal outcomes than women with mild preeclampsia.8

2 — — Chapter B: Medical Complications of Pregnancy PREECLAMPSIA Definitions slide 6 Preeclampsia is a multi-organ disease process characterized by hypertension and proteinuria. To meet diagnostic criteria for preeclampsia, systolic blood pressure must be 140 mm Hg or greater, or diastolic blood pressure 90 mm Hg or greater, on at least two occasions no less than six hours apart.9-11 Blood pressure should be measured at each prenatal visit using an appropriate sized cuff with the patient in an upright position.9-10 If the initial blood pressure is elevated then a repeat measurement is checked after a 10-minute rest. An increase in blood pressure of 30 mm Hg systolic or 15 mm Hg diastolic is no longer included in the definition of preeclampsia11 as similar increases are common in uncomplicated pregnancies.

The diagnostic threshold for proteinuria is 300mg in a 24-hour specimen. Two random urine dipstick measurements greater than or equal to 1+ (30 mg/dl) six hours apart correlates with significant proteinuria. However, a 24-hour determination is the gold standard because urine dipsticks can be affected by dehydration and bacteriuria. A random urine can rule out significant proteinuria if the protein/creatinine ratio is less than 0.19.12 Proteinuria occurs late in the course of preeclampsia and is not useful for screening.9

Edema supports the diagnosis of preeclampsia when it is pronounced and generalized (affecting the face or hands), but is no longer a diagnostic criteria. One third of preeclamptic women never have edema, while non-dependent edema is seen in a significant proportion of women without preeclampsia.1 slide 7 Preeclampsia is defined as mild or severe based upon the degree of blood pressure elevation and proteinuria, and the presence of clinical symptoms resulting from involvement of the kidneys, brain, liver and cardiovascular system.

Pathogenesis and Risk Factors The etiology of preeclampsia remains unknown and no single causal factor links all theories (Table 1).13 Risk factors are listed in Table 2.

Table 1: Theories Associated with the Pathophysiology of Preeclampsia

Genetic predisposition (maternal, paternal, thrombophilias)14-17

Immunologic phenomena

Abnormal placental implantation (defects in trophoblasts and spiral arterioles)18-19

Vascular endothelial damage

Angiogenic factors (low level of placental growth factor)20

Platelet activation

Cardiovascular maladaptation and vasoconstriction

— Chapter B: Medical Complications of Pregnancy— 3 Table 2: Preeclampsia Risk Factors21

Nulliparity

Maternal age greater than 40

Multiple gestation

Preeclampsia in a prior pregnancy (particularly if severe or prior to 32 weeks)

Chronic hypertension

Chronic renal disease

Antiphospholipid syndrome

Elevated body mass index

Diabetes mellitus

Note: Previously, young maternal age was considered a risk factor, but this was not supported by a systematic review.21

Prevention Randomized controlled trials fail to support a role for routine prenatal supplementation with calcium, magnesium, omega three fatty acids, or antioxidant vitamins E and C to prevent preeclampsia.22-25 slide 8 Calcium supplementation has, however, been shown to reduce the risk of hypertension and preeclampsia for women at high risk and for women with low dietary calcium intakes.26 Calcium supplementation also reduces the incidence of neonatal mortality and severe maternal morbidity in healthy nulliparous normotensive women.27

Antiplatelet agents (e.g. low dose aspirin), have small to moderate benefits for prevention. A Cochrane analysis of low-dose aspirin for women at increased risk for preeclampsia demonstrated that 69 women would need to be treated to prevent one case of preeclampsia, and 227 treated to prevent one fetal death. In the subgroup of women at highest risk due to previous severe preeclampsia, diabetes, chronic hypertension, renal or autoimmune disease, only 18 women needed to be treated with low-dose aspirin to prevent one case of preeclampsia.28

Further research is needed to assess which women benefit most and the optimal treatment regimens for preventing preeclampsia with calcium or aspirin.

Management of Mild Preeclampsia Expectant management of women with mild preeclampsia may include biweekly blood pressures, slide 10 weekly lab tests (CBC, either ALT or AST, LDH, uric acid, and creatinine), periodic 24-hour urine protein collections, twice weekly non-stress tests (NSTs) and weekly amniotic fluid indices (AFIs) or weekly biophysical profiles (BPPs), and ultrasounds for fetal growth every three weeks.1,29

The decision to bring about delivery by induction or cesarean section involves balancing prematurity-related risks with the risk of worsening preeclampsia. Delivery is generally not indicated for women with mild preeclampsia until 37 to 38 weeks and should occur by 40 weeks (Figure 1).1,29

4 — — Chapter B: Medical Complications of Pregnancy Figure 1: Recommended management of mild gestational hypertension or preeclampsia29

Mild hypertension-preeclampsia

Maternal and fetal evaluation

> 40 weeks of gestation > 37 weeks of gestation Bishop score > 6 Noncompliant patient YES > 34 weeks of gestation Delivery Labor or rupture of membranes Abnormal fetal testing Intrauterine growth restriction NO

< 37 weeks 37-39 weeks Prostaglandins

Inpatient or outpatient management Maternal and fetal evaluation

Worsening material or fetal condition 40 weeks of gestation Bishop score > 6 at > 37 weeks Labor

Reprinted with permission. Sibai BM. Diagnosis and Management of Gestational Hypertension and Pre-eclampsia. Obstetrics and Gynecology, 2003; 102:181-192. Copyright © Lippincott Williams & Wilkins. All rights reserved.

slide 11 Severe Preeclampsia Diagnostic criteria for severe preeclampsia are listed in Table 3. Severe preeclampsia causes multi-system deterioration that may be gradual or fulminant. Severe headache, visual disturbances, and progressive hyperreflexia may signal impending generalized seizures (eclampsia). Increasing peripheral vascular resistance stresses the cardiovascular system, and pulmonary edema may result. A decreased glomerular filtration rate may progress to oliguria and acute renal failure. Hemodilution usually lowers pregnancy creatinine levels; levels above 0.9 mg/dl in pregnancy are abnormal. Liver manifestations include elevated transaminases, subcapsular hemorrhage with right upper quadrant pain, and capsular rupture with life-threatening intraabdominal bleeding. Preeclampsia-related coagulopathies include HELLP syndrome and disseminated intravascular coagulation (DIC). Obstetric complications include IUGR, abruption, and fetal or maternal demise.11

— Chapter B: Medical Complications of Pregnancy— 5 Table 3: Diagnostic Criteria for Severe Preeclampsia11

• Blood pressure equal to or exceeding 160 mm Hg systolic or 110 mm Hg diastolic on at least two occasions six hours apart • Proteinuria of five grams or more in a 24-hour urine specimen or 3+ or greater on two random urine specimens collected at least 4 hours apart • Any of the following signs and symptoms: – Oliguria less than 500 ml per 24 hours – Cerebral or visual disturbances – Pulmonary edema – Epigastric or right upper-quadrant pain – Impaired liver function – Thrombocytopenia – Fetal growth restriction

Management of Severe Preeclampsia slide 12 The progression of severe preeclampsia is only reversed by delivery. Patients with severe preeclampsia should be admitted to the hospital, placed on bedrest, and carefully monitored.29 The overall treatment goals are to 1) prevent seizures, 2) lower blood pressure in order to prevent maternal cerebral hemorrhage, and 3) expedite delivery based on a decision that takes into account disease severity and fetal maturity.

Maternal Evaluation and Stabilization Sample admitting orders for severe preeclampsia are outlined in Table 4. Fluid management slide 13 requires special care. Excessive fluid administration can result in pulmonary edema, ascites and cardiopulmonary overload, while too little fluid can exacerbate an already constricted intravascular volume and lead to further end-organ ischemia. Urine output should be maintained above 30 ml/hr using IV lactated ringers or normal saline.30 Total intravenous fluid intake should be limited to 100 ml per hour30-31 and total oral and intravenous fluid intake should not exceed 125 ml per hour or 3000 ml per day. A foley catheter allows accurate monitoring of urine output. A Swan-Ganz catheter may optimize fluid management if pulmonary edema and renal failure are present.11,30

Plasma volume is reduced among women with preeclampsia, suggesting that increasing plasma volume with colloid solution might improve uteroplacental circulation, and perinatal outcomes. However, risk/benefit data regarding this practice is lacking.32

In addition to the basic laboratory investigation for mild preeclampsia, the woman with signs of severe disease may be evaluated with serum albumin, LDH, peripheral blood smear and coagulation profile. A low serum albumin level may reflect vascular endothelial damage with albumin leak. The LDH and peripheral smear may indicate hemolysis.1

6 — — Chapter B: Medical Complications of Pregnancy Table 4: Admitting Orders for Severe Preeclampsia

Bed rest with seizure precautions.

Vital signs (blood pressure, pulse, respiration), deep tendon reflexes, and neurologic checks every 15 to 60 minutes until stable.

Accurate intake and output; foley catheter if needed.

Intravenous: Lactated Ringer’s at 50 to 125 ml/hr to maintain urine output 30 to 40 ml/hr. Total intake (intravenous and oral) should not exceed 125 ml/hr or 3000 ml/day.

External monitor for contractions and fetal heart rate.

Labs: Dipstick urine for protein on admission

Begin 24-hour urine for total protein and creatinine clearance

Complete blood count and platelet count

BUN, creatinine

AST or ALT

Uric acid

LDH

Peripheral blood smear

Coagulation profile (INR/PT, aPTT, other______)

Medications: 1) Magnesium sulfate (see Table 5 for dosing).

2) For systolic BP greater than 160 or diastolic BP greater than 110, give one of the following to achieve systolic BP 140 to 160 and/or diastolic BP 90 to 100 Hydralazine 5 to 10 mg IV every 15 to 30 minutes.

–or-

Labetalol 20 mg IV initial dose. If the initial dose is not effective, double the dose to 40 mg and then 80 mg at 10 minute intervals until target blood pressure is reached or you have given a total 220 mg within one hour.1,29 The maximum dose of IV labetalol is 300 mg in a 24-hour period.

3) Calcium gluconate one gram IV: keep at bedside in case of respiratory depression due to magnesium sulfate.

— Chapter B: Medical Complications of Pregnancy— 7 Magnesium Sulfate (MgSO4) slide 14, 15 Magnesium sulfate helps prevent seizures in women with preeclampsia33-35 and is more effective in preventing recurrent seizures in eclamptic patients than phenytoin, diazepam or a lytic cocktail (chlorpromazine, promethazine and pethidine).34,36-39 The Magpie trial demonstrated that 63 women with severe preeclampsia need to receive magnesium sulfate prophylaxis to prevent one eclamptic seizure.33 Whether to give MgSO4 to women with mild preeclampsia in developed countries is controversial, as the estimated incidence of eclamptic seizures in this population is only 0.5 percent. Assuming 50 percent are preventable by MgSO4,33 then 400 women need to be treated to prevent one eclamptic seizure.40 Blood pressure is only mildly elevated in 30 to 60 percent of women who develop eclampsia.41 Due to the inability to predict who will seize, women with mild preeclampsia are often treated with MgSO4.

Magnesium sulfate works by slowing neuromuscular conduction and depressing central nervous system irritability. It does not have significant effects on lowering blood pressure. A quarter of women have side effects, especially flushing.42 Table 5 presents the standard dosing regimen.

Table 5: Magnesium Sulfate in Preeclampsia11 slide 16

Loading dose: four to six grams mixed in 100 ml, given IV over 15 to 20 minutes, followed by a continuous infusion of two grams per hour Monitor: Magnesium levels (therapeutic range = 4 to 7 mg/dl) Reflexes Mental status Respiratory status Urine output

Magnesium sulfate is excreted by the kidneys. Women with normal renal function do not require ongoing monitoring of serum magnesium levels as long as they continue to have deep tendon reflexes (DTRs) and over 30 ml urine output per hour.41 For women with absent reflexes, elevated serum creatinine or decreased urine output, magnesium levels are checked every four to six hours after the loading dose and the infusion rate is adjusted accordingly.41

Magnesium toxicity can lead to respiratory paralysis, central nervous system depression and slide 17 cardiac arrest. With magnesium overdose, vital functions are lost in a predictable sequence. If DTRs are present, magnesium concentrations are rarely toxic.43 The MgSO4 infusion should be discontinued and a magnesium level checked immediately when DTRs are lost, the respiratory rate is less than 12 per minute, or urine output is less than 30 ml per hour.43 Maternal deaths have resulted from overdoses due to administration of improperly prepared solutions.44 The antidote for MgSO4 overdose is one gram of calcium gluconate (10 ml of a 10 percent solution) infused intravenously over two minutes.30 Avoid rapid intravenous administration or extravasation. Use calcium gluconate with caution in women with renal failure, severe hyperphosphatemia, or acidosis.

8 — — Chapter B: Medical Complications of Pregnancy slide 18 Antihypertensive Medications The optimal level of blood pressure control in pregnancies complicated by hypertension is unknown.2,45 Less tight control may decrease the risk of infants being small for gestational age, but may potentially increase the risk of respiratory distress syndrome, severe hypertension, antenatal hospitalization, and proteinuria at delivery.2,5 Although traditional recommendations are based on diastolic blood pressures, a retrospective review of 28 women with severe preeclampsia who experienced a cerebrovascular accident demonstrated that over 90 percent had systolic BP over 160, but only 12.5 percent had diastolic BP over 110.46

There are several possible choices for the antihypertensive agent depending on whether the goal is acute or chronic control. For acute management, intravenous labetalol and hydralazine are commonly used.1,47 Doses for intravenous labetalol and hydralazine are given in Table 4. A Cochrane review of antihypertensive medicine for severe hypertension in pregnancy showed no evidence that one agent had superior effectiveness.47 The role of hydralazine as a first line choice has been questioned by a metaanalysis showing more maternal hypotension, tachycardia, and headaches compared to other antihypertensives.45 The need for intravenous antihypertensives, either in repeated doses or by continuous infusion, indicates an unstable patient who is likely to need continuous monitoring and careful management. For the severe preeclamptic undergoing expectant management remote from term, oral labetalol and nifedipine are acceptable options.29

Fetal Surveillance Assessment for uteroplacental insufficiency may be achieved utilizing non-stress tests, amniotic fluid measurements and biophysical profiles. Umbilical Doppler systolic-to-diastolic ratios may detect early uteroplacental insufficiency but are not included in the NHBPEP Working Group recommendations. Monitoring frequency varies depending on the clinical context. A common regimen for mild preeclampsia includes biweekly non-stress tests (NSTs) and weekly measurement of amniotic fluid index with biophysical profile for follow-up of non-reactive NSTs.1,29 Severe preeclamptics undergoing expectant management may receive daily monitoring. Ultrasound for assessment of fetal growth should be repeated every three weeks. Corticosteroids are administered to accelerate lung maturity for fetuses between 24 and 34 weeks gestation, either betamethasone (two doses of 12 mg given intramuscularly 24 hours apart) or dexamethasone (four doses of 6 mg given intramuscularly 12 hours apart).29 slide 19 Delivery Decisions in Severe Preeclampsia Delivery is the only known cure for preeclampsia. Decisions regarding the timing and mode of delivery are based on a combination of maternal and fetal factors. Fetal factors include gestational age, evidence of lung maturity and signs of fetal compromise on antenatal assessment. Maternal factors include the degree to which the hypertension is controllable and any clinical or laboratory signs of impending decompensation. Patients with resistant severe hypertension or other signs of maternal or fetal deterioration should be delivered within 24 hours, irrespective of gestational age or fetal lung maturity. Fetuses greater than 34 weeks, or those with documented lung maturity, may also be delivered within 24 hours.

There are insufficient data to recommend an “interventionist” versus an “expectant management” approach for severe preeclampsia between 24 and 34 weeks.48 Consultation is indicated.49-50 An “interventionist” approach advocates induction or cesarean delivery 12 to 24 hours after corticosteroid

— Chapter B: Medical Complications of Pregnancy— 9 administration. An “expectant” approach aims to give corticosteroids, stabilize the woman and fetus and delay delivery even longer, if possible.48 Expectant management, with close monitoring of the mother and fetus, reduces neonatal complications and neonatal stay in the newborn intensive care nursery.49-50 In one study, bed rest and close monitoring of women between 28 to 32 weeks with preeclampsia prolonged pregnancy an average of 15 days, resulting in fewer days in the neonatal intensive care unit and fewer cases of respiratory distress syndrome and necrotizing enterocolitis, without increasing maternal morbidity.50 Contraindications to expectant management of severe preeclampsia include persistent severe symptoms, multiorgan dysfunction, severe IUGR (estimated fetal weight less than 5th percentile), suspected placental abruption or non-reassuring fetal testing.50

Attempted vaginal delivery is recommended for severe preeclampsia if there is no evidence of maternal or fetal compromise, or other obstetric contraindication.1 Cesarean delivery in severe preeclampsia is indicated for some obstetric conditions, e.g. status epilepticus or non-reassuring fetal heart rate pattern. Some experts recommend Cesarean delivery for fetuses under 30 weeks when the cervix is not ripe, but a trial of induction may be considered here as well.1,29

Postpartum Management of Preeclampsia slide 20 Most patients with preeclampsia respond promptly to delivery, with decreased blood pressure, diuresis, and general clinical improvement. Eclampsia may occur postpartum: the greatest risk for postpartum eclampsia is within the first 48 hours.41 Magnesium sulfate should be continued for 12 to 24 hours, or occasionally longer if the clinical situation warrants.29,42 Patients on MgSO4 require ongoing monitoring of blood pressure and urine output, as they are at risk for pulmonary edema due to intravenous fluid overload, mobilization of third space fluids, and decreased renal function. There are no reliable data on postpartum hypertensive management,51 however oral nifedipine is commonly used.29

ECLAMPSIA The generalized seizures of eclampsia represent a life-threatening emergency, requiring immediate slide 21 attention while honoring the concept of “primum non nocere” or “do no harm.”

Pathophysiology Preeclampsia is characterized by a loss of regulation of cerebral blood flow and plasma exudation into the brain. The precise mechanism leading to seizures is unknown, but may include cerebral edema, transient vasoconstriction, ischemia, or microinfarcts.41

Clinical Course Eclampsia may be preceded by increasingly severe preeclampsia, or may appear unexpectedly in a patient whose preeclampsia seems relatively mild, with minimally elevated blood pressure and no proteinuria or edema. In one large series, 15 percent of the cases had diastolic blood pressure below 90 mmHg.52 It is rare for eclampsia to occur prior to 20 weeks gestation in the absence of gestational trophoblastic disease.

Eclamptic seizures usually last from 60 to 90 seconds, during which time the patient is without respiratory effort. A post-ictal phase may follow with confusion, agitation, and combativeness. The timing of an eclamptic seizure can be antepartum (53 percent), intrapartum (19 percent), or postpartum (28 percent).52

10 — — Chapter B: Medical Complications of Pregnancy slide 22 Management An eclamptic seizure is dramatic and disturbing. The attending clinician is challenged to maintain a purposeful calm and to avoid unnecessary interventions that can result in iatrogenic complications.41,53 1. Do not attempt to shorten or abolish the initial convulsion by using drugs such as diazepam or phenytoin. These drugs can lead to respiratory depression, aspiration, or frank respiratory arrest, particularly when they are given repetitively or used in combination with MgSO4. Further, phenytoin is less effective than MgSO4 in preventing recurrent eclamptic seizures.37 2. Protect the airway and minimize the risk of aspiration by placing the woman on her left side and suctioning her mouth. Summon an anesthetist (or someone equally skilled in intubation) to be immediately available.53 The adult CPR recovery position helps a semiconscious or unconscious person breathe and permits fluids to drain from the nose and throat so they are not aspirated. 3. Prevent maternal injury. Falls from the bed can result in contusions or fractures, and head injury may result from violent seizure activity. Close observation, soft padding and use of side rails on the bed may help prevent these complications. 4. Give MgSO4 to control convulsions. If the patient with preeclampsia has already received a prophylactic loading dose of MgSO4 and is receiving a continuous infusion when the seizure occurs, an additional two grams should be given intravenously. Otherwise, a six-gram loading dose of MgSO4 should be given intravenously over 15 to 20 minutes, followed by a maintenance infusion of two grams per hour. A total of eight grams MgSO4 should not be exceeded over a short period of time.41,53 A serum magnesium level may be obtained four hours after the loading dose, and the maintenance infusion adjusted accordingly. After the convulsion has ended, administer supplemental oxygen. When the patient has stabilized, plan for prompt delivery. Avoid the temptation to perform immediate cesarean delivery for a self limited seizure episode.

Maternal and Fetal Outcomes in Eclampsia The maternal death rate following an eclamptic seizure was 0.6 percent, in a large US series,52 but was considerably higher, 14 percent, in a sizeable Mexican study.54 Twenty percent of pregnancy- related deaths in the United States from 1979 to 1992 were due to preeclampsia/eclampsia of which approximately 50 percent occurred in women with eclampsia.55 Abruption (seven to 10 percent), disseminated intravascular coagulation (seven to 11 percent), aspiration pneumonia (two to three percent) and cardiopulmonary arrest (two to five percent) are serious causes of morbidity and mortality in eclamptic women.

Most fetal eclampsia-related morbidity and mortality result from prematurity, growth restriction and placental abruption. During an eclamptic seizure, the fetus will frequently manifest hypoxia- related bradycardia. In the absence of other serious medical or obstetric complications, the fetus usually recovers.

In rural or remote areas, maternity care providers need to balance the risk of transfer versus the benefits of tertiary maternal and neonatal care. When the patient is adequately treated with MgSO4 and stabilized, a successful transfer can be made. Close coordination with consultants at the receiving institution is mandatory.

— Chapter B: Medical Complications of Pregnancy— 11 HELLP SYNDROME The acronym HELLP describes a variant of severe preeclampsia characterized by Hemolysis, slide 23 Elevated Liver enzymes, and Low Platelets.56 HELLP syndrome poses significant challenges to maternity care providers: first, to maintain a high index of suspicion for the diagnosis, particularly in pregnant patients who are remote from term and may not be hypertensive; and second, to manage the life-threatening, multi-organ system complications. Research has yet to elucidate why a subset of women with severe preeclampsia develop the HELLP syndrome but most do not.

Risk Factors and Clinical Presentation of HELLP Syndrome slide 24 HELLP syndrome occurs in less than one percent of pregnancies, but up to 20 percent of pregnancies complicated by severe preeclampsia.57 The clinical presentation of HELLP syndrome is quite variable. At diagnosis, 30 percent are postpartum, 18 percent are term, 42 percent are preterm (27 to 37 weeks gestation) and 11 percent are extremely preterm (less than 27 weeks).57 The most common presenting complaints are right upper quadrant or epigastric pain, nausea, and vomiting. Many patients will give a history of malaise or non-specific symptoms suggesting an acute viral syndrome.58 A subset presents with severe preeclampsia symptoms of headache and visual disturbances. Advanced coagulopathy may cause hematuria or gastrointestinal bleeding. Physical findings include right upper quadrant and epigastric tenderness. As 12 to 18 percent of women with HELLP are normotensive and 13 percent do not have proteinuria, clinicians must consider HELLP in patients who lack these classic findings of preeclampsia.58

Differential Diagnosis of HELLP Syndrome slide 25 One of the most difficult challenges posed by HELLP syndrome is its extensive differential diagnosis. The differential of right upper quadrant pain includes cholecystitis, hepatitis, acute fatty liver of pregnancy, gastroesophageal reflux, gastroenteritis and pancreatitis. Urinalysis or kidney function abnormalities may suggest pyelonephritis, hemolytic uremic syndrome, or ureteral calculi. Other causes of thrombocytopenia in pregnancy include: gestational thrombocytopenia, pseudothrombo- cytopenia, HIV, immune thrombocytopenic purpura, systemic lupus erythematosus, antiphospholipid syndrome, hypersplenism, DIC, thrombotic thrombocytopenic purpura, hemolytic uremic syndrome, congenital thrombocytopenias and medications.59 A high index of suspicion is the key to diagnosing HELLP syndrome. Any patient with complaints of right upper quadrant or epigastric pain, nausea, vomiting, or any signs of preeclampsia should be evaluated with a complete blood count, platelet count, and liver enzyme determinations.60

Laboratory Diagnosis and Classification of HELLP Syndrome slide 26 Laboratory tests are used both for diagnosis and as an indicator of severity in HELLP syndrome. A falling platelet count and rising serum LDH (indicative of both hemolysis and liver dysfunction) reflect the severity of the disease, and improvements in these parameters predict recovery. Thrombocytopenia also forms the basis of a commonly used classification system.31 Table 6 lists some commonly used laboratory criteria for the diagnosis of HELLP syndrome.58

12 — — Chapter B: Medical Complications of Pregnancy Table 6: Criteria for Laboratory Diagnosis of HELLP Syndrome31,60 Hemolysis Abnormal peripheral blood smear (evidence of damaged erythrocytes – schistocytes, burr cells, helmet cells) Serum bilirubin greater than, or equal to, 1.2 mg/dL LDH greater than 600 IU/L Elevated Liver Enzymes AST (SGOT) greater than 70 IU/L ALT (SGPT) greater than 40 IU/L LDH greater than 600 IU/L Low Platelet Count Less than 100,000 per mm,3 or Class 1 – less than or equal to 50,000 per mm3 Class 2 – greater than 50,000 but less than or equal to 100,000 per mm3 Class 3 – greater than 100,000 but less than 150,000 per mm3

In addition, when the platelet count is less than 50,000 per mm,3 or active bleeding occurs, fibrinogen, fibrin degradation products or d-dimer, prothrombin and partial thromboplastin times should be checked to rule out superimposed DIC.

Management of HELLP Syndrome Management of HELLP follows the general guidelines for severe preeclampsia. All women with HELLP should receive MgSO4 from the time of hospital admission until 24 to 48 hours postpartum.58 Management issues specific to HELLP syndrome include the following: slide 27 1. Corticosteroids: Although a few small randomized controlled trials have demonstrated improvement in laboratory measurements, particularly platelet counts, with the use of high dose steroids,58 a Cochrane analysis did not demonstrate improved maternal or fetal outcomes beyond the known benefits of corticosteroids for fetuses less than 34 weeks.61 The only randomized, double-blind, placebo controlled clinical trial failed to demonstrate any improved maternal outcomes with antepartum or postpartum use of dexamethasone except for a shorter time to platelet count recovery in women with platelet counts below 50,000.62 Increased platelet counts may permit the use of regional anesthesia.63 High dose corticosteroids are not recommended for routine use in women beyond 34 weeks gestational age or postpartum. 2. Blood products: Fresh frozen plasma, platelets, and packed red blood cells may be needed to correct coagulation defects or acute hemorrhage. Women with platelets greater than 50,000/µl are unlikely to bleed, but intrapartum platelet transfusions are indicated if the count dips below 20,000/µl or in the presence of significant bleeding (e.g. ecchymosis, bleeding from puncture sites, bleeding gums). Regional anesthesia is safe with platelet counts above 100,000/µl and should be avoided if platelet counts are less than 50,000/µl. Between 50,000/µl and 100,000/µl regional anesthesia may be safe, but “its use in such patients will require a consensus among the obstetrician, anesthesiologist, and patient.”59 Platelet transfusions usually increase platelets by 10,000/µl per unit and are given 6 to10 units at a time.59

— Chapter B: Medical Complications of Pregnancy— 13 3. Spontaneous rupture of a subcapsular liver hematoma: This is a life threatening complication that must be suspected in any patient with HELLP who develops shock and massive ascites. Emergent laparotomy may be life saving. A subcapsular hematoma may be suggested by right upper quadrant, epigastric or shoulder pain. The diagnosis is confirmed by CT or US. If unruptured, the hematoma may be monitored with serial US or CT scans in a facility with a readily available vascular or general surgeon and a blood bank aware of the potential need for massive transfusions.60

Delivery and Postpartum Management The decision regarding timing of delivery is weighted toward earlier delivery for women with HELLP than for women with severe preeclampsia without HELLP. Specifically, infants greater than 28 weeks gestation are routinely delivered 24 to 48 hours after the first maternal dose of dexamethasone or betamethasone is administered.60 Conservative management of HEELP remains experimental and in most women the clinical course is too rapid to wait for the complete steroid course before initiating delivery.58

The choice between vaginal and cesarean delivery should be based on obstetric factors (e.g. parity and cervical ripeness), fetal maturity, and the severity of medical complications.58,60 Cesarean delivery carries special risks, such as bleeding due to thrombocytopenia and difficulty controlling blood pressure due to depleted intravascular volume. The surgeon may elect to place a subfascial drain or perform secondary skin closure due to expected continued oozing. After delivery, some women with HELLP syndrome experience a period of clinical and laboratory deterioration before recovery. Magnesium sulfate infusion is continued for at least 24 hours. The platelet count typically reaches its nadir and the LDH its peak 24 to 48 hours after delivery.64 Unfortunately, postpartum deterioration sometimes progresses to include hepatic rupture, renal failure, pulmonary edema, ascites, pleural effusion, postpartum hemorrhage, or DIC. These patients may require prolonged intensive care with continuous cardiac monitoring, central lines, respirator care, dialysis and other major interventions. There is a one percent risk of maternal mortality.58 Clinical signs of recovery include a decreasing blood pressure, mobilization of fluid from peripheral edema, ascites, or pleural effusions, and subsequent diuresis.

ACUTE FATTY LIVER OF PREGNANCY slide 28 Acute fatty liver of pregnancy (AFLP) is a rare condition that occurs in the third trimester and may be initially diagnosed as HELLP syndrome due to similarities in clinical and laboratory findings. The incidence of AFLP is approximately one in 7,000 to 16,000 pregnancies.65,66 In the past, fetal and maternal mortality were each as high as 85 percent, but with earlier recognition and prompt delivery mortality is now less than 15 percent.65,66

The pathophysiology of AFLP involves abnormal hepatic mitochondrial function that leads to accu- mulation of fat droplets in hepatocytes, and culminates in fulminant hepatic failure if left untreated. The etiology is unknown. Women carrying infants with a mutation affecting fatty acid oxidation, Long-Chain 3 Hydroxyacyl CoA Dehydrogense deficiency (LCHAD), have an increased incidence of AFLP. Infants of mothers with AFLP should be tested for LCHAD, as 19 percent of AFLP cases are associated with this mutation. Affected infants have a 75 to 90 percent mortality rate, which can be decreased dramatically through dietary treatment.67

14 — — Chapter B: Medical Complications of Pregnancy AFLP presents in the third trimester with vomiting (71 to 75 percent of cases), upper abdominal pain (43 to 50 percent), malaise (31 percent) and jaundice (28 to 37 percent).65-66 Physical examination findings are non-specific, and the liver size is normal or small. With disease progression, liver failure develops with signs of coagulopathy, asterixis, encephalopathy and coma. There may be ascites (due to portal hypertension) and gastrointestinal bleeding secondary to severe vomiting, esophagi- tis, and associated coagulation disorders. slide 29 Differential Diagnosis Most women with AFLP are misdiagnosed on initial hospital admission: preeclampsia and hepatitis are the most common initial diagnoses.65

Many clinical features of AFLP overlap those of preeclampsia and the HELLP syndrome, and patients may have both diseases. Approximately half of patients with AFLP will have hypertension, proteinuria or edema. Acute hepatitis and liver damage secondary to drugs or toxins should also be considered in the differential diagnosis.

The diagnosis of AFLP is heavily dependent on laboratory findings. Early in the disease course, bilirubin is elevated and the international normalized ratio (INR) and activated partial thromboplastin time (aPTT) are prolonged, while the platelet count is only mildly decreased (100,000 to 150,000). This contrasts with HELLP, where significant thrombocytopenia is an early finding and bilirubin is usually normal.31,68 In AFLP, the AST and ALT are usually elevated, but not to the extent that would be expected with acute infectious hepatitis. Appropriate serologic tests for acute infectious hepatitis can further clarify the diagnosis. In one case series, all women with AFLP had laboratory evidence of DIC, including markedly decreased antithrombin III levels.65 Although hypoglycemia was found in all patients in one study, it was only present in 50 percent of patients in another study and its absence does not exclude AFLP. Radiologic tests are of limited usefulness in diagnosing AFLP, as ultrasound studies, computed tomography (CT) scans and magnetic resonance imaging (MRI) of the liver all have high false negative rates.65 Liver biopsy can confirm the diagnosis of AFLP but is invasive and not usually necessary in order to proceed with treatment.65,68

Treatment The most important treatment for AFLP is delivery, since the disease never remits and severe complications can develop if delivery is delayed. As is the case with preeclampsia and HELLP syndrome, the choice between vaginal and cesarean delivery should be based on obstetric factors, fetal maturity and the severity of medical complications.65 Hepatotoxic general anesthetics should be avoided. Coagulopathy should be corrected although infusion of antithrombin has not been shown to improve clinical outcomes.65 Hypoglycemia may be corrected with infusions of 10 percent dextrose, supplemented by boluses of 50 percent dextrose.65 If diagnosis and delivery are accomplished early, postpartum improvement is generally rapid. Rarely, liver transplantation has been required for multisystem failure that does not improve with delivery.69 slide 30 PERIPARTUM CARDIOMYOPATHY (PPCM) The incidence of PPCM is between one in 3000 to 4000 births.70 Its importance lies in its high mortality rate, which has been estimated at five to 20 percent.71,72 PPCM is responsible for eight percent of maternal deaths in the United States, making it the fifth leading cause of maternal mortality.73 By definition, PPCM is heart failure developing in the last month of pregnancy or within

— Chapter B: Medical Complications of Pregnancy— 15 five months of delivery in a woman without another identifiable cause of the heart failure. Left ventricular systolic dysfunction is documented with echocardiography.70

The etiology of PPCM remains unknown but evidence points to myocarditis, perhaps due to a weakened immune response to viral infection of the myocardium.70 Other etiologies that have been suggested but not proven include maladaptation to the normal hemodynamic stress of pregnancy, stress-activated cytokines and genetic factors. There are cases of familial PPCM.70

Initial diagnosis may be delayed because the signs and symptoms of systolic dysfunction, including dyspnea, fatigue, tachypnea, and lower extremity edema, are common in the last month of pregnancy and immediate postpartum period. The differential diagnosis includes cardiomyopathy due to other etiologies such as valvular disease, ischemia or myocardial dysfunction secondary to preeclampsia, dyspnea from respiratory disease including pulmonary embolism, amniotic fluid embolism or pneumonia as well as iatrogenic fluid overload.

The management of PPCM during pregnancy differs from standard congestive heart failure treat- slide 31 ment, because ACE inhibitors are contraindicated in pregnancy and care must be taken to avoid excess diuresis with its accompanying risk of uteroplacental insufficiency. Close collaboration between maternal fetal medicine and cardiology specialists is recommended when the diagnosis is made prior to delivery. Severe cases that do not improve with at least two weeks of standard therapy may be treated with immunosuppressive therapy if an endomyocardial biopsy demonstrates myocarditis.70,74 The prognosis for women with PPCM depends on the degree of myocardial dysfunction.72 Future pregnancies are at risk for recurrent, life-threatening PPCM. Women whose cardiac function does not recover fully should be discouraged from conceiving again.70,72

VENOUS THROMBOEMBOLISM (VTE) DURING PREGNANCY Definitions slide 32 VTE includes deep venous thrombosis (DVT), a blood clot in the venous system of the lower extremities, and pulmonary embolism (PE), which occurs when thrombus from the deep venous system lodges in the pulmonary arteries.

Incidence and Clinical Significance VTE complicates 1.3 per 1000 pregnancies and is the leading cause of maternal mortality in developed countries.75-77 The importance of timely diagnosis is underscored by the fact that up to 25 percent of patients with untreated DVT develop PE, and undiagnosed PE has a mortality rate of 30 percent.78 Morbidity is also common: following DVT, 29 to 79 percent of women suffer post-thrombotic syndrome, with chronic leg pain and swelling, varicose veins, skin discoloration, and ulceration.79

Pathophysiology and Risk Factors slide 33 VTE develops as a result of multiple interacting risk factors.80 The classic predisposing factors of hypercoagulation, venous stasis, and vascular damage are present in every pregnancy and postpartum.81 Hypercoagulability of pregnancy results from an increased concentration of procoagulant factors II, VII, X, and fibrin, combined with decreased activity of the endogenous anticoagulant, protein S.81 Stasis results, from increased venous distension, and obstruction of the inferior vena cava by the gravid uterus. Reduction in venous flow is evident by 13 weeks gestation, reaches a

16 — — Chapter B: Medical Complications of Pregnancy nadir at 36 weeks, and returns to non-pregnant levels approximately six weeks postpartum.76 Pelvic vascular damage may occur from the trauma of vaginal or cesarean delivery.81 Table 7 lists additional risk factors for VTE in pregnancy. Overall, the risk of VTE is five to six times higher for a pregnant woman than a non-pregnant woman of the same age.76

Table 7: Risk Factors for VTE76,82

– Thrombophilic disorders – Infection/sepsis – Multiparity (more than four deliveries) – Dehydration – Age greater than 35 years – Major medical problems (mechanical heart valve, – Weight over 80 kg inflammatory bowel disease,nephrotic syndrome, sickle cell disease, myeloproliferative disorders) – Severe varicose veins – Cesarean delivery, especially if emergent – Hyperemesis – Post-partum hemorrhage – Preeclampsia – Prolonged bed rest or immobility during travel

Thrombophilic Disorders Among the important risk factors for VTE are the thrombophilic disorders, which may be inherited slide 34 or acquired. Approximately 50 percent of women with VTE in pregnancy have a thrombophilic disorder, compared to only 10 percent of the general population in the United States.76 The inherited thrombophilias are listed in Table 8. Factor V Leiden and prothrombin G20210A mutations are the most common.83 Women with protein C and protein S deficiencies have an eight-fold increased risk of pregnancy-related VTE.84

Table 8: Inherited Thrombophilias85

Factor V Leiden mutation Prothrombin G20210A mutation Methylene tetrahydrofolate reductase mutation Antithrombin deficiency Protein C deficiency Protein S deficiency

Universal screening for thrombophilia is not recommended;76,86 however, testing is recommended for women with a personal or family history of thrombosis or thrombophilia.76,87 Accurate interpretation of screening tests requires knowledge of the effects of pregnancy and other disorders. Normal pregnancy decreases protein S levels.88 Antithrombin and Protein C levels remain normal throughout pregnancy,81,88 but protein C resistance increases during the second and third trimesters.88 Massive thrombus decreases antithrombin levels; nephrotic syndrome is associated with decreased antithrombin levels, and liver disease with decreased protein C and S levels.89

— Chapter B: Medical Complications of Pregnancy— 17 Antiphospholipid antibodies are the most common and significant acquired thrombophilic defects. Antiphospholipid syndrome (APS) in pregnancy is defined by the presence of antiphospholipid antibodies and at least one clinical manifestation, most commonly thrombosis or recurrent pregnancy loss.90 The syndrome is classified as primary or secondary, i.e., associated with connective tissue diseases such as systemic lupus erythematosis (SLE).86,90 Laboratory testing for APS includes a several-step evaluation for lupus anticoagulant (LA) and a determination of anticardiolipin antibody (ACA) titers.85 LA cannot be quantified and is reported as present or negative.86 Only moderate to high titers (> 20 units) of anticardiolipin IgM or IgG are considered sufficient laboratory criteria for the diagnosis of APS.86 A positive result for either LA or ACAs is adequate for the laboratory confirmation of APS if the result is persistent on least two occasions several weeks apart.86 Antinuclear antibody (ANA) can screen for autoimmune diseases, such as SLE, which can affect pregnancy similarly to APS and may cause secondary APS.

DEEP VENOUS THROMBOSIS slide 35 Clinical signs and symptoms DVT during pregnancy is at least as common as postpartum thrombosis, and occurs with equal frequency in all three trimesters.85 Ninety percent of DVTs during pregnancy occur in the left leg, perhaps because of compression of the left iliac vein by the right iliac arteries (Figure 2). Seventy- two percent of DVTs in pregnancy occur in the iliofemoral vein compared with nine percent in the calf veins; the former are more likely to embolize.76 In non-pregnant patients, only 55 percent of DVTs are on the left and only nine percent are in the iliofemoral vein.76

Figure 2: Compression of the Left Iliac Vein by the Right Iliac Arteries

Deep venous thrombosis may have a subtle clinical presentation and may be difficult to distinguish from gestational edema. Typical symptoms are unilateral leg pain and swelling. More than two centimeters difference in lower leg circumference deserves investigation. Pain with dorsiflexion of the foot (Homan’s sign) is quite nonspecific as it is found in more than 50 percent of patients without DVT.91

18 — — Chapter B: Medical Complications of Pregnancy Less than 10 percent of women with signs and symptoms of DVT have the diagnosis confirmed by objective testing.92 Definitive diagnosis is essential due to the need for acute treatment, evaluation for underlying thrombophilia, and prophylaxis in future pregnancies. slide 36 Diagnostic testing When DVT is strongly clinically suspected, anticoagulation should be given until results of confirmatory tests are available.89 The first-line diagnostic test for DVT is Doppler ultrasound.89 A Doppler study indicating deep vein thrombosis in the affected leg is sufficient to recommend a full course of therapeutic anticoagulation.89 Negative Doppler results with low clinical suspicion do not require anticoagulation. However, with high clinical suspicion, anticoagulation is advisable despite a negative study. If a repeat Doppler study a week later is negative, treatment can be discontinued.89 Venography continues to serve as the reference standard for the diagnosis of DVT, but clinically has been replaced by noninvasive tests.

In non-pregnant patients, computed tomography (CT) and magnetic resonance imaging (MRI) have equivalent or better sensitivities and specificities than Doppler ultrasound for the detection of DVT.93 CT and MRI also allow better delineation of the inferior vena cava and pelvic veins than does sonography.93 However, CT has the disadvantages of radiation exposure, contrast toxicity, lack of universal availability and higher cost. MRI remains a second-line diagnostic tool due to lack of availability and higher costs.93

Measurement of D-dimer levels may provide additional diagnostic information. The D-dimer level has a high negative predictive value but a low positive predictive value; therefore, a positive (high-level) D-dimer always requires confirmatory testing.89 In non-pregnant patients, a negative rapid ELISA VIDAS D-dimer has sensitivity and negative predictive values of over 99 percent for detecting DVT.94 A conventional ELISA D-dimer has a sensitivity of 96 percent; when combined with a low clinical likelihood of DVT, the negative predictive value is more than 99.5 percent.94,95 Note that reference ranges for D-dimer vary; a “negative” D-dimer is in the normal range and a “positive” D-dimer exceeds the reference range.

Treatment The optimal treatment of VTE during pregnancy remains controversial because of a lack of randomized controlled trials involving pregnant women.75,85

In non-pregnant women, randomized controlled trials have demonstrated that low-molecular weight heparins (LMWHs) have equivalent or better efficacy than unfractionated heparin (UFH) and are safe to use for the treatment of acute DVT.96-98 Although higher quality research is needed, case series demonstrate similar results for LMWHs in pregnancy, and expert opinion supports its use.99-102 LMWH doses are described in the section, Anticoagulation in Pregnancy. slide 37 PULMONARY EMBOLISM Clinical signs and symptoms In contrast to DVT, which is as common during pregnancy as postpartum, at least two thirds of PEs occur postpartum.103 Dyspnea and tachypnea are the most common presenting symptoms of PE. The clinical picture varies from mild dyspnea and tachypnea accompanied by chest pain to dramatic cardiopulmonary collapse.

— Chapter B: Medical Complications of Pregnancy— 19 Diagnostic Testing slide 38 An approach to the diagnosis of suspected PE using non-invasive testing is outlined in Figure 3. Because of a high negative predictive value, a negative (normal level) D-dimer in combination with low clinical probability is sufficient to exclude the diagnosis of PE.104,105

Figure 3: Algorithm for Diagnosis of Pulmonary Embolism104

Clinical suspicion of PE

Low Moderate or High

D-dimer 1) Spiral CTA or 2) VQ scan Positive Negative PE excluded

1) Diagnostic spiral 1) Normal 1) Non-diagnostic CT with intraluminal spiral CT spiral CT filling defect(s) in pulmonary arteries 2) Normal 2) Low or moderate or VQ Scan probability VQ scan 2) High-probability VQ

PE excluded Venous Doppler PE diagnosedB of bilateral lower extremities

Negative Positive Consider repeat DVT diagnosed, testing or additional PE diagnosed studiesB,C presumptively

Negative Positive

PE excluded PE diagnosed

A) Spiral CT refers to multidetector-row CT scanner that allows visualization of subsegmental pulmonary arteries. B) The prevalence of PE with a high-probability scan and low clinical suspicion is 50 percent. Confirmatory testing may be indicated.104 C) PE is essentially excluded when lung scanning and venous Doppler are negative in the setting of low clinical suspicion.104 Doppler ultrasound, Spiral CT, or VQ scan may be repeated, or MRI or pulmonary angiography obtained if clinical suspicion remains high despite negative testing.

20 — — Chapter B: Medical Complications of Pregnancy Increasingly, clinicians are using a spiral computerized tomography (CT) scan as the first imaging study to evaluate for PE in pregnancy.78 First-generation single-detector-row spiral CT scanners have a positive predictive value of only 85 percent104 and are only 30 percent sensitive for subsegmental defects, which account for 20 percent of symptomatic PE.104 Newer multidetector-row spiral CT scanners allow improved visualization of the segmental and subsegmental pulmonary arteries106 and have positive and negative predictive values of 99 percent, comparable to pulmonary angiography.107 Multidetector-row spiral CT scanners allow quicker scanning of the lung, avoiding respiratory movement and artifact: the 16-slice CT can image the entire chest with submillimeter resolution in less than 10 seconds.108 Spiral CT scanning can identify an alternative diagnosis in about two thirds of cases in which PE is not present; however, it may detect suspicious-appearing abnormalities that require further evaluation or even biopsy but actually are benign.109 Fetal exposure to radiation is lower with a spiral CT than a ventilation-perfusion (V/Q) scan110 and fetal exposure to spiral CT nonionic contrast appears safe.78 A cost-benefit analysis supported the conclusion that spiral CT is the preferred diagnostic strategy for suspected PE in pregnant women.78

Although the V/Q lung scan has been the traditional diagnostic test of choice, the diagnosis of PE is inconclusive in up to 80 percent of V/Q scans.85 Moreover, the sensitivity of high-probability scans is only 41 percent.111 The V/Q scan remains an important diagnostic tool when spiral CT is not available or is contraindicated.

MRI is an attractive option because it does not expose the fetus to ionizing radiation, and it is as sensitive and specific as a spiral CT in diagnosing PE.78,112 Disadvantages of MRI include expense, questions about accessibility, and the fact that it is relatively unstudied in pregnancy.78,109

Arterial blood gas determination, chest x-ray, and electrocardiogram may help determine the clinical likelihood of PE or may suggest other conditions.

Pulmonary angiography is the gold standard for diagnosing PE, but has a mortality rate of 0.5 percent. It is generally reserved for special circumstances when non-invasive testing is not feasible.104 slide 39,40 TREATMENT When PE is suspected, diagnostic and therapeutic actions should be initiated simultaneously.89 Stabilization is the first priority; airway, breathing and circulation (ABCs) should be addressed immediately, as described in Chapter K: Maternal Resuscitation. Anticoagulation may be started empirically if clinical suspicion is high, then discontinued if PE is excluded.

While more research is needed, it appears that LMWH is equivalent in efficacy and superior in safety to UFH in the initial treatment of PE in pregnancy.99-101,113 It is also acceptable to treat PE initially with UFH and then convert to LMWH once the patient is stabilized. Dosage and duration of anticoagulation is similar to that for DVT89,114 and is reviewed in the following section, Anticoagulation in Pregnancy.

If anticoagulation is contraindicated or repeat PE occurs despite adequate anticoagulation, it may be necessary to insert a filter in the inferior vena cava.89 Anticoagulation is continued after the filter is placed.

In the case of life-threatening massive PE, thrombolytic therapy, percutaneous catheter thrombus fragmentation or surgical embolectomy may be utilized, depending on local expertise.89,115

— Chapter B: Medical Complications of Pregnancy— 21 Anticoagulation in pregnancy When clinical findings and the results of diagnostic testing show DVT or PE, therapeutic anticoagulation is indicated. Anticoagulation options include low molecular weight heparins (LMWHs) such as enoxaparin and dalteparin; unfractionated heparin (UFH); and, in the postpartum period, warfarin (Coumadin®).

Heparin is considered safe for use during pregnancy because it does not cross the placenta and is not secreted in breast milk.99 For many years UFH was considered the standard; however, because of their safety profiles and ease of monitoring, the low molecular weight heparins (LMWHs) are replacing UFH as the drug of choice for treatment and prophylaxis.75,100 LMWHs are at least as effective as UFH and are less likely to cause side effects including thrombocytopenia, symptomatic osteoporosis, bleeding and allergy.75,116 There is no evidence favoring one LMWH over another.100,116

Warfarin should be avoided during pregnancy. It crosses the placenta and increases the risk of miscarriage and stillbirth, embryopathy — nasal hypoplasia and/or stippled epiphyses — when used in the first trimester, CNS abnormalities when used in any trimester, and maternal and fetal hemorrhage when used near time of delivery.89 However, warfarin is safe for breastfeeding.89

Table 9 lists the baseline laboratory evaluation that may be obtained prior to initiating anticoagulation.

Table 9: Baseline Laboratory Tests for Initiating Anticoagulation

Thrombophilia profile (See Table 8)

Creatinine (LMWHs are contraindicated with abnormal renal function)

Liver function tests (warfarin is contraindicated with significantly abnormal liver function)

Complete blood count with platelet count

PT/INR

Activated partial thromboplastin time (aPTT)

Therapeutic anticoagulation should continue for six months from diagnosis.89,114 If a woman is still pregnant six months later, the LMWH dose can be lowered to a prophylactic level.89 Acceptable therapeutic doses for LMWH are listed in Table 10. In small trials involving nonpregnant adults, once daily injection of LMWH appears to be as safe and effective for the acute treatment of VTE as twice daily injections.117 Due to the shorter half-life of LMWH in pregnancy, further research is needed before once daily dosing can be recommended for treating VTE in pregnant women.102 Dosages of LMWH should be adjusted in the setting of renal insufficiency, notably with severe preeclampsia.116

Table 10: Therapeutic Dosing of Low Molecular Weight Heparin82,102

Enoxaparin (Lovenox®) Dalteparin Tinzaparin (100 units/mg) (Fragmin®) (Innohep®)

Therapeutic dose 1 mg/kg subcutaneously 90 to 100 units/kg 90 units/kg SQ (SQ) every 12 hrs SQ every 12 hrs every 12 hrs

22 — — Chapter B: Medical Complications of Pregnancy The optimal protocol for monitoring treatment with LMWHs has not been established. It is not necessary to follow the aPTT as with UFH. Whether to follow Anti-Xa levels is controversial, and the target range is not well established.118 The use of Anti-Xa levels is becoming less common as experience with LMWHs increases.89 A platelet count seven to ten days after initiation of therapy and every month thereafter is recommended.89,100

Intravenous (IV) and/or subcutaneous (SQ) forms of UFH may be used instead of LMWH for the initial treatment of DVT or PE in pregnancy. UFH may be chosen over LMWH in some settings for reasons of cost or availability. Recommended dosages and monitoring are described in Table 11.

Table 11: Therapeutic Dosages and Monitoring of Intravenous (IV) and Subcutaneous (SQ) UFH

IV regimen119 • IV bolus of 5000 international units (IU) • Followed by a continuous infusion of 1300 IU per hour • aPTT every six hours during the first 24 hours • Thereafter, check the aPTT at least daily and adjust dosage to achieve aPTT in the therapeutic range of 1.5 to 2.5 times the mean laboratory control value

SQ regimen with IV loading dose120 • IV bolus of 5,000 IU • Followed by 15,000 to 20,000 IU SQ bid • Monitor aPTT and adjust SQ dose to achieve aPTT of 1.5 to 2.5 times the control value • Once therapeutic, monitor aPTT and adjust dosage every one to two weeks

For postpartum DVT or PE, warfarin may be started concomitantly with heparin.121 Because of an initial inhibition of Protein C, warfarin can cause a hypercoagulable state for the first three to five days of therapy.122 The LMWH or UFH should be continued until the target INR of 2.0 to 3.0 is achieved for two consecutive days.89 Typically, this level of anticoagulation is obtained within five days.123 LMWH and warfarin therapy can be started concomitantly in an outpatient setting for selected patients who are medically stable, with a supportive home environment and access to daily monitoring until the INR is therapeutic.124

Delivery Management of the Anticoagulated Patient Evidence is lacking for the best intrapartum management for the woman who has required therapeutic anticoagulation for VTE in pregnancy.89,102 Issues are how to alter heparin doses slide 41 during labor and under what conditions is it safe to use neuraxial (epidural, intrathecal, or spinal) analgesia or anesthesia.

For scheduled cesarean deliveries or inductions, LMWH or UFH should be discontinued 24 hours prior to the procedure.85,102 For scheduled cesarean deliveries, a prophylactic dose of LMWH or UFH should be given by three hours after the operation and a treatment dose recommenced that evening.89 Post-operative compression stockings are recommended. Because of a two percent risk of wound hematoma with UFH and LMWH, drains may be used and the skin closed with staples or interrupted sutures to allow better drainage.125

— Chapter B: Medical Complications of Pregnancy— 23 Women receiving full therapeutic anticoagulation who go into spontaneous labor should be instructed to discontinue heparin injections at the onset of regular contractions.85 It is recommended to withhold neuraxial analgesia until 24 hours after the last dose of LMWH.85 For women on UFH, the aPTT may be monitored during labor and epidural given when the value is normal.85,102 A prophylactic dose of LMWH can be given three hours after removal of an epidural catheter, and a therapeutic dose can be resumed the next morning.125

Women who are on lower, prophylactic doses of UFH or LMWH are at low risk for spinal hematoma. Neuraxial analgesia may be given 12 hours following the last dose of once-daily prophylactic LMWH. With UFH doses of 5000 U or less, given subcutaneously every 12 hours, neuraxial analgesia is considered safe as long as the aPTT and platelet counts are also normal.85

Prophylaxis slide 42 Prophylaxis against VTE in pregnancy may be required antenatally for women with a history of DVT or PE and for those with a known history of thrombophilia. While better studies are needed, the LMWHs appear to be the safest and most effective form of thromboprophylaxis in pregnancy.99,100,126 Prophylactic doses of LMWHs are listed in Table 12. Subcutaneous UFH may be used as a lower cost alternative to LMWH; doses are listed in Table 13.

Table 12: Prophylactic Dosage for LMWHs82

Enoxaparin (Lovenox®) Dalteparin Tinzaparin (100 units/mg) (Fragmin®) (Innohep®)

Body weight 50 to 90 kg 40 mg SQ daily 5000 units SQ daily 4500 units SQ daily

Body weight < 50 kg 20 mg SQ daily 2500 units SQ daily 3500 units SQ daily

Body weight > 90 kg 40 mg SQ every 12 hrs 5000 units SQ every 4500 units SQ every 12 hrs 12 hours

Table 13: Prophylactic Dosage for UFH127

First trimester 5,000 International Units (IU) SQ BID

Second trimester 7,500 IU SQ BID

Third trimester 10,000 IU SQ BID

There are no well designed studies of aspirin thromboprophylaxis in pregnancy. Low dose aspirin may be safely prescribed in certain situations where the risk of thrombosis is increased, but not high enough to warrant heparin prophylaxis.82,128-130 One example is a woman with antiphospholipid antibodies but no personal or family history of thrombosis or other thrombophilia.82

Clinical indications for anticoagulant prophylaxis and recommendations for when to initiate and discontinue therapy are summarized in Table 14. Consultation should be considered for complex conditions such as antithrombin deficiency, which may require a higher than typical prophylactic dose.82

24 — — Chapter B: Medical Complications of Pregnancy Women with mechanical heart valves should be transferred to a high-risk specialist or managed with close consultation. The manufacturer of enoxaparin issued a warning against its use for the treatment of pregnant patients with mechanical heart valves because of an undisclosed number of post-marketing reports of thrombosed valves in patients receiving enoxaparin.131

Table 14: Clinical Indications for Anticoagulant Prophylaxis

Indication 1: Personal history of DVT or PE, no known thrombophilia 1.A. DVT or PE with thrombogenic event (such as a hip fracture or a prolonged surgery) Start prophylaxis: Controversial:92,132 the patient and the care giver may decide whether to use antenatal heparin prophylaxis; regardless of this decision, postpartum prophylaxis is recommended82,85,92 Stop prophylaxis: six weeks postpartum82,85,92 1.B. DVT or PE with no thrombogenic event Start: As early in pregnancy as possible82,85,92 Stop: six weeks postpartum;82,85,92 those with recurrent or life-threatening events may require longer or lifetime prophylaxis133

Indication 2: Personal history of DVT or PE and known thrombophilia Start: As early in pregnancy as possible82,85,92 Stop: six weeks postpartum82,85,92 Women with antiphospholipid syndrome or antithrombin deficiency and a history of thrombosis should receive prophylaxis for life;102,134 Women with any thrombophilia and recurrent or life-threatening events may require lifetime prophylaxis.133

Indication 3: Known thrombophilia and no history of DVT or PE 3.A. Antithrombin deficiency Start: As early in pregnancy as possible82,135 Stop: Continue throughout lifetime134 3.B. Homozygous Factor V Leiden Start: As early in pregnancy as possible76 Stop: six weeks postpartum76,82,134 3.C. Antiphospholipid antibodies Start: Low-dose aspirin +/- heparin as early in pregnancy as possible82,86 Stop: six to eight weeks postpartum.76,86 Women with antiphospholipid syndrome identified because of recurrent miscarriage and with no history of thrombosis may not require LMWH for six weeks postpartum but should receive LMWH for at least three to five days, especially if they have other risk factors.82 3.D. Protein C deficiency Start: As early in pregnancy as possible76 Peripartum and postpartum may be sufficient if no family history of thrombophilia, no severe protein C deficiency (of less than 50 percent) and no additional risk factor such as immobilization, hospitalization, surgery, infection or thrombophlebitis76 Stop: six weeks postpartum76 3.E. Protein S deficiency Start: As early in pregnancy as possible76 Peripartum and postpartum may be sufficient if no family history of thrombophilia and no additional risk factor such as immobilization, hospitalization, surgery, infection or thrombophlebitis76 Stop: six weeks postpartum76 3.F. 2 or more minor risk factors (such as heterozygous factor V Leiden and heterozygous prothrombin G20210A mutations) Start: As early in pregnancy as possible76 Stop: six weeks postpartum76 3.G. Single heterozygous factor V Leiden or heterozygous prothrombin G20210A mutation Start: No prophylaxis indicated unless family history of VTE and additional risk factor such as immobilization, hospitalization, surgery, infection or thrombophlebitis76 Prophylaxis started peripartum or postpartum when indicated76 Stop: four to six weeks postpartum76

— Chapter B: Medical Complications of Pregnancy— 25 While routine postpartum thromboprophylaxis is not indicated,75 pharmacological and mechanical prophylaxis are recommended in certain circumstances. Postpartum prophylactic anticoagulation may be indicated due to preexisting risk factors or new delivery-related risk factors including prolonged labor, mid-forceps and immobility after delivery.82 Graduated compression stockings (GCS) or pneumatic compression stockings (PCS) may also be considered. A decision analysis concluded that the optimal post-cesarean thromboprophylaxis strategy is routine use of PCS.136 A Cochrane review showed that GCS are effective in diminishing the risk of DVT in nonpregnant post-surgery patients and that GCS combined with another method of prophylaxis is more effective than GCS alone.137

Summary Pregnancy is a natural process that involves many complex physiologic changes. Multiple medical slide 43 challenges can evolve during pregnancy. This chapter attempts to better participants’ understanding of the risk factors, diagnosis and management of hypertensive disorders of pregnancy, AFLP, peripartum cardiomyopathy and VTE. The key to diagnosis of these problems is clinical vigilance coupled with appropriate lab or imaging studies. A common clinical challenge is balancing maternal and fetal well-being in diagnostic and treatment decisions.

SUMMARY OF TABLE OF RECOMMENDATIONS Strength of Recommendation - A Magnesium sulfate is the treatment of choice for women with preeclampsia to prevent eclamptic seizures (NNT=100) and placental abruption (NNT=100).42 Magnesium sulfate is more effective in preventing recurrent eclamptic seizures than diazepam (NNT=8) or phenytoin (NNT=8).38,39

Strength of Recommendation - B Low dose aspirin (75 to 81 mg daily) has small to moderate benefits for prevention of preeclampsia (NNT=69), preterm delivery (NNT=83), and fetal death (NNT=227) in women at high risk for developing preeclampsia.28 Calcium supplementation may decrease the incidence of hypertension (NNT=4) and preeclampsia (NNT=5.5) among women at high risk of developing those conditions and women with low calcium intakes (reduction in hypertension NNT=4 and reduction in preeclampsia NNT=7).26 For managing severe preeclampsia between 24 and 34 weeks gestation, there are insufficient data to determine whether an interventionist approach (induction or cesarean delivery 12 to 24 hours after corticosteroid administration) is superior to expectant management. Expectant management, with close monitoring of the mother and fetus, reduces neonatal complications and neonatal stay in the newborn intensive care nursery.48 Either intravenous labetalol or hydralazine may be used for treating severe hypertension in pregnancy, as neither has demonstrated superior effectiveness.1,47

26 — — Chapter B: Medical Complications of Pregnancy Strength of Recommendation - C Chronic hypertension in pregnancy, in women without target organ damage, does not require treatment unless the blood pressure is persistently greater than 150 to 180/100 to 110.1,2,4,45 For women with mild pre-eclampsia, delivery is generally not indicated until 37 to 38 weeks and slide 10, 11 should occur by 40 weeks.1,29 The following recommendations are SOR-C as applied to pregnant women, but are based on higher quality evidence from studies involving non-pregnant adults: Low molecular weight heparins (LMWHs) are recommended for the treatment of acute DVT and PE due to equivalent or superior efficacy and safety compared to unfractionated heparin(UFH). Specific outcomes favoring LMWHs over UFH are as follows:*98 • Prevention of recurrent VTE after initial treatment (NNT=100) • Prevention of recurrent VTE within three to six months (NNT=50) • Reduction in incidence of major hemorrhagic event (NNT=100) • Reduction in overall mortality (NNT=100). LMWHs are the agents of choice for antenatal thromboprophylaxis.82 Multidetector-row CT is the imaging modality of choice to evaluate for PE because the diagnostic accuracy is equivalent to pulmonary angiography107 and superior to V/Q scanning,**85,111 and radiation exposure is less than a V/Q scan.110

* Strength of Recommendation A in non-pregnant adults ** Strength of Recommendation B in non-pregnant adults

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30 — — Chapter B: Medical Complications of Pregnancy 93. Kanne J, Lalani T. Role of computed tomography 107. Quiroz R, Kucher N, Zou K, et al. Clinical validity of a and magnetic resonance imaging for deep venous negative computed tomography scan in patients with thrombosis and pulmonary embolism. Circulation. suspected pulmonary embolism: a systematic review. 2004;109:115-121. (Level III) JAMA. 2005;293:2012-2017. (Level II) 94. Michiels J, Freyburger G, Graaf F, et al. Strategies 108. Schoepf U, Goldhaber S, Costello P. Spiral com- for the safe and effective exclusion and diagnosis of puted tomography for acute pulmonary embolism. deep vein thrombosis by the sequential use of clinical Circulation. 2004;109:2160-2167. (Level III) score, d-dimer testing, and compression ultrasonogra- 109. Ramzi D, Leeper K. DVT and pulmonary embolism: phy. Semin Thromb Hemost. 2000;26:657-667. (Level II) part I. diagnosis. Am Fam Physician. 2004;69:2829- 95. Stein P, Hull R, Patel C, et al. D-dimer for the exclu- 2840. (Level III) sion of acute venous thrombosis and pulmonary 110. Winer-Muram H, Boone Jennings S, Mabie W, embolism: a systematic review. Ann Intern Med. Lombardo G. Pulmonary embolism in pregnant 2004;140:589-602. (Level II) patients: fetal radiation dose with helical CT. 96. Gould M, Dembitzer A, Doyle R, et al. Low molecular Radiology 2002;224:487-492. (Level III) weight heparins compared with unfractionated 111. The PIOPED investigators. Value of the ventila- heparin for treatment of acute venous thrombosis. tion/perfusion scan in acute pulmonary embolism: A meta-analysis of randomized, controlled trails. results of the Prospective Investigation of Pulmonary Ann Intern Med. 1999;130:800-809. (Level I) Embolism Diagnosis (PIOPED). JAMA. 1990;263:2753- 97. Martinelli I, de Stefano V, Taiolo E, Paciaroni K, Rossi 2759. (Level I) E, PM M. Inherited thrombophilia and first venous 112. Kline J, Johns K, Colucciello S, EG I. New diagnostic thromboembolism during pregnancy and the puerpe- tests for pulmonary embolism. Ann Emerg Med. rium. Thromb Haemost. 2002;87:791-795. (Level II) 2000;35:168-180. (Level II) 98. Van Dongen C, Van den Belt A, Prins M, Lensing A. 113. Kaaja R, Ulander V. Treatment of acute pulmonary Fixed dose subcutaneous low molecular weight hepa- embolism during pregnancy with low molecular rins versus adjusted dose unfractionated heparin for weight heparin: three case reports. Blood Coagul venous thromboembolism. Cochrane Database Syst Fibrinolysis. 2002;13:637-640. (Level III) Rev. 2004;4. (Level I) 114. Schulman S, Rhedin A, Lindmarker P, et al. A 99. Laurent P, Dussart G, Bonal J, et al. Low molecular comparison of six weeks with six months of oral weight heparins: a guide to their optimum use in anticoagulant therapy after a first episode of venous pregnancy. Drugs 2002;62:463-477. (Level III) thromboembolism. N Engl J Med. 1995;332:1661-1665. 100. McColl M, Greer I. Low-molecular-weight heparin (Level I) for the prevention and treatment of venous throm- 115. Pillny M, Sandmann W, Luther B, et al. Deep venous boembolism in pregnancy. Curr Opin Pulm Med. thrombosis during pregnancy and after delivery: indi- 2004;10:371-375. (Level III) cations for and results of thrombectomy. J Vasc Surg 101. Rodie V, Thomson A, Stewart F, et al. Low molecular 2003;37:528-532. (Level III) weight heparin for the treatment of venous throm- 116. Gouin-Thibault I, Pautas E, Siguret V. Safety profile of boembolism in pregnancy: a case series. BJOG. different low-molecular weight heparins used at thera- 2002;109:1020-1024. (Level III) peutic dose. Drug Saf. 2005;28:333-349. (Level III) 102. Bates S, Greer I, Hirsh J, Ginsberg J. Use of anti- 117. Van Dongen C, MacGillavry M, Prins M. Once versus thrombotic agents during pregnancy: the seventh twice daily LMWH for the initial treatment of venous ACCP conference on antithrombotic and thrombolytic thromboembolism. Cochrane Database Syst Rev. therapy. Chest. 2004;126:627S-644S. (Level III) 2005;3. (Level I) 103. Heit J, Kobbervig C, James A, Petterson T, Bailey 118. Shiach C. Monitoring of low molecular weight heparin K, Melton L. Trends in the incidence of venous in pregnancy. Hematology. 2003;8:47-52. (Level III) thromboembolism during pregnancy or postpartum: a 30-year population-based study. Ann Intern Med. 119. Hyers T, Hull R, Weg J. Antithrombotic therapy 2005;143:697-706. (Level II) for venous thromboembolic disease. Chest. 1995;108:335S-351S. (Level III) 104. Kearon C. Diagnosis of pulmonary embolism. CMAJ-JAMC 2003;168:183-194. (Level III) 120. Prandoni P, Carnovali M, Marchori A. Subcutaneous adjusted-dose unfractionated heparin vs fixed-dose 105. Wells P, Anderson D, Rodger M, et al. Excluding pul- low-molecular-weight heparin in the initial treatment monary embolism at the bedside without diagnostic of venous thromboembolism. Arch Intern Med. imaging: management of patients with suspected 2004;164:1077-1083. (Level I) pulmonary embolism presenting to the emergency department using a simple clinical model and 121. Ansell J, Hirsh J, Poller L, Bussey H, Jacobson A, d-Dimer. Ann Intern Med. 2001;135:98-107. (Level II) Hylek E. The pharmacology and management of the vitamin K antagonists: the Seventh ACCP Conference 106. Perrier A, Roy P, Sanchez O, et al. Multidetector-row on Antithrombotic and Thrombolytic Therapy. Chest. computed tomography in suspected pulmonary 2004;126:204S-233S. (Level III) embolism. N Engl J Med. 2005;352:1760-1768. (Level II)

— Chapter B: Medical Complications of Pregnancy— 31 122. Clouse L, Comp P. The regulation of hemostasis: The 135. Conard J, Horellou M, van Dreden P, Le Compte T, protein C system. N Engl J Med. 1986;314:1298. (Level III) Samama M. Thrombosis in pregnancy and congenital 123. Hull R, Raskob G, Rosenbloom D, et al. Heparin for deficiencies in AT III, protein C or protein S: study of 78 5 days as compared with 10 days in the initial treat- women. Thromb Haemost. 1990;63:319-320. (Level III) ment of proximal vein thrombosis. N Engl J Med. 136. Quinones J, James D, Stamilio D, Cleary K, Macones 1990;322:1260-1264. (Level I) G. Thromboprophylaxis after cesarean delivery. 124. Ageno W, Steidl L, Ultori C, et al. The initial phase of Obstet Gynecol. 2005;106:733-740. (Level II) oral anticoagulation with warfarin in outpatients with 137. Amaragiri S, Lees T. Elastic compression stockings deep venous thrombosis. Blood Coagul Fibrinolysis. for prevention of deep vein thrombosis. Cochrane 2003;14:11-14. (Level III) Database Syst Rev. 2000;3. (Level I) 125. Greer I. The acute management of venous thromboembolism in pregnancy. Curr Opin Obstet Gynecol 2001;13:569-575. (Level III) Editor’s note: The section Human Immunodeficiency Virus (HIV) in Pregnancy, found in the 2000 Edition of the 126. Pettila V, Leinonen P, Markkola A, Hiilesmaa V, Kaaja R. Postpartum bone mineral density in women treated ALSO syllabus, has been eliminated from the 2006 Update. for thromboprophylaxis with unfractionated heparin HIV in pregnancy is an important topic that will be covered or LMW heparin. Thromb Haemost. 2002;87:182-186. in the Global ALSO Manual. In the interim, ALSO course (Level I) participants are referred to the following resources: 127. Kent N. Prevention and treatment of venous thrombo- 1. Public Health Service Task Force Recommendations embolism (VTE) in obstetrics. SOGC Clinical Practice for Use of Antiretroviral Drugs in Pregnant HIV-1- Guidelines 2000;95. (Level III) Infected Women for Maternal Health and Interventions 128. CLASP (Collaborative Low-dose Aspirin Study in to Reduce Perinatal HIV-1 Transmission in the United Pregnancy) Collaborative Group. CLASP: a random- States - November 17, 2005 ized trail of low-dose aspirin for the prevention and http://aidsinfo.nih.gov/ContentFiles/PerinatalGL.pdf treatment of pre-eclampsia among 9364 pregnant 2. Prenatal and perinatal human immunodeficiency women. Lancet. 1994;343:619-629. (Level I) virus testing: expanded recommendations. ACOG 129. Pulmonary Embolism Prevention (PEP) Trail Committee Opinion No. 304. American College of Collaborative Group. Prevention of pulmonary Obstetricians and Gynecologists. Obstet Gynecol embolism and deep venous thrombosis with low dose 2004;104:1119–24 aspirin: Pulmonary Embolism Prevention (PEP) trail. 3. Scheduled Cesarean Delivery and the Prevention Lancet. 2000;355:1295-1302. (Level I) of Vertical Transmission of HIV Infection. ACOG 130. Antiplatelet Trialists’ Collaboration. Collaborative Committee Opinion Number 234, May 2000 overview of randomized trails of antiplatelet therapy- III. Reduction in venous thrombosis and pulmonary embolism by antiplatelet prophylaxis among surgical and medical patients. BMJ. 1994;308:235-246. (Level I) 131. Seshadri N, Goldhaber S, Elkayam U, et al. The clinical challenge of bridging anticoagulation with low- molecular-weight heparin in patients with mechanical prosthetic heart valves: an evidence-based compara- tive review focusing on anticoagulation options in pregnant and nonpregnant patients. Am Heart J. 2005;150:27-34. (Level III) 132. Pabinger I, Grafenhofer H, Kyrle P, et al. Temporary increase in the risk for recurrence during pregnancy win women with a history of venous thromboembolism. Blood. 2002;100:1060-1062. (Level II) 133. Schulman S, Granquist S, Holstrom M, et al. The duration of anticoagulant therapy after a second episode of thromboembolism. N Engl J Med. 1997;336:393. (Level I) 134. Blanchard E, Ansell J. Extended anticoagulation therapy for the primary and secondary prevention of venous thromboembolism. Drugs. 2005;65:303-311. (Level III)

32 — — Chapter B: Medical Complications of Pregnancy Hypertension in Pregnancy Interim Update June 2014

The Medical Complications of Pregnancy chapter is currently being updated. This document is a summary update for courses until the complete revision is available in late 2014. The current slides HAVE BEEN updated to reflect this update.

In late 2013, ACOG published: American College of Obstetricians and Gynecologists; Task Force on Hypertension in Pregnancy. Hypertension in pregnancy. Report of the American College of Obstetricians and Gynecologists’ Task Force on Hypertension in Pregnancy. Obstet Gynecol. 2013; 122:1122-1131. http://www.acog.org/Resources_And_Publications/Task_Force_and_Work_Group_Reports/Hypertension_in_Pregnancy

A summary of the new recommendations:

Definitions: • Hypertensive disorders of pregnancy still classified as: o Chronic hypertension o Gestational hypertension o Preeclampsia o Chronic hypertension with superimposed preeclampsia • Most changes have to do with diagnosis and management of preeclampsia

Preeclampsia • The terms mild and severe preeclampsia have been eliminated. New categories are preeclampsia with and without severe features. • The change is to emphasize that severe features may develop at any time in women with preeclampsia and to emphasize vigilance in looking for these features

Preeclampsia Diagnosis • No longer dependent on presence of proteinuria • BP > 140/90 on two occasions four hours apart, (or BP > 160/110 once) new after 20 weeks EGA AND • > 300 mg on 24 hour protein OR > 0.3 protein/creatinine ratio OR dipstick of +1 protein (if other two methods are not available) OR • any of the following if proteinuria not present: o Platelets <100,000 o Creatinine > 1.1 OR doubling of creatinine in absence of other renal disease o Doubling of AST or ALT

• Preeclampsia with severe features: o BP > 160/110 four hours apart on bedrest (unless on antihypertensive) o Platelets < 100,000 o Doubling of AST or ALT AND/OR severe RUQ not explained by other pathology o Creatinine > 1.1 OR doubling of creatinine in absence of other renal disease o Pulmonary edema o New cerebral or visual disturbances

o No longer part of definition of severe preeclampsia: Intrauterine growth restriction > 5g on 24 hour protein

Preeclampsia prevention • If early-onset preeclampsia with preterm delivery < 34 weeks OR preeclampsia in more than one pregnancy, give low dose aspirin from late first trimester • Recommendation against vitamin C or E supplementation, bed rest or salt-restriction (low quality evidence)

Preeclampsia and gestational hypertension management • For mild gestational hypertension (BP < 160/110) and preeclampsia without severe features o No magnesium (low quality evidence) o No antihypertensives • Delivery recommended at 37 weeks

Pre-term management non-severe preeclampsia and gestational hypertension • Daily self-assessment preeclampsia symptoms and fetal kick count • BP measurement twice weekly, at least one in the office • Platelets, liver enzymes, weekly • Protein assessment weekly in women with gestational hypertension but no need to repeat once diagnostic proteinuria is present • Antenatal testing (Low quality evidence) • Serial growth ultrasounds • Umbilical Doppler only in setting of IUGR • Do not administer anti-hypertensives outpatient • Do not recommend bed rest (Low quality evidence)

Severe preeclampsia at > 34 weeks or if unstable woman or fetus • Stabilization and delivery

Severe preeclampsia at <34 weeks and stable woman and fetus • Expectant management only at facilities with appropriate perinatal and neonatal resources • Antihypertensives if BP > 160/110 • Do not base delivery decisions on amount of proteinuria (therefore no need for repeating 24 hour urine protein or urine protein/creatinine ratio)

• Delivery once stable if severe preeclampsia before fetal viability • Give steroids and try to delay delivery for 48 hours if severe preeclampsia, viable fetus at <34weeks EGA and: o Preterm premature rupture of membranes o Labor o Platelets < 100,000 o Persistent elevated AST or ALT (over twice upper limit normal) o Growth restriction (< 5 % EFW for EGA) o Severe oligo (< 5cm) o Reverse end-flow on umbilical Doppler o New or worsening renal dysfunction • Give steroids (unless IUFD) but don’t delay delivery if severe preeclampsia, fetus at < 34 weeks EGA and: o Uncontrollable severe HTN o Eclampsia o Pulmonary edema o Placental abruption o DIC o Category III fetal tracing o Intrapartum fetal demise

Magnesium • Recommended for eclampsia or preeclampsia with severe features • If magnesium indicated, continue magnesium intraoperatively usually for 24 hours • Not recommended for non-severe preeclampsia or gestational hypertension

HELLP syndrome • Deliver after stabilization if previable • Deliver after stabilization if > 34 weeks EGA • If viable and < 34 weeks EGA, administer steroids and delay delivery 24 to48 hours if maternal and fetal condition stable (Low quality evidence)

Regional anesthesia • Preferred for cesarean if time allows

Postpartum • Monitor closely for 72 hours in hospital (or outpatient equivalent) • Follow up in clinic at seven to ten days • If women develop new hypertension with headache or blurred vision or preeclampsia with severe hypertension, magnesium is recommended (Low quality evidence) • Women with postpartum BP > 150/100 for four to six hours or women with BP>160/110 should be started on antihypertensive (Low quality evidence)

Chronic hypertension • Home blood pressure monitoring is recommended for women with poorly controlled chronic hypertension • Home blood pressure monitoring is recommended for women with suspected white coat hypertension (low quality evidence) • Weight loss and extremely low sodium diet is NOT recommended for women with chronic hypertension in pregnancy (low quality evidence) • If women with chronic hypertension who normally exercise and BP well controlled, continued exercise in pregnancy is recommended (low quality evidence) • Antihypertensive therapy recommended if BP>160/105 • Recommended antihypertensives: labetolol, nifedipine, methyldopa • Not recommended: ACE, ARB, renin inhibitor, mineralcorticoid receptor antagonist • Target blood pressure for those on antihypertensive is 120 to 160/80 to105 (low quality evidence) • Serial growth ultrasounds are recommended (low quality evidence) • Umbilical Doppler only recommended if IUGR • Antenatal testing recommended if: (low quality evidence) o On antihypertensive o Superimposed preeclampsia o IUGR • If chronic hypertension and no other maternal or fetal complications delivery is not recommended until > 38 weeks EGA

Chronic hypertension with superimposed preeclampsia • Watch carefully for signs and symptoms of superimposed preeclampsia which occurs in about 20% of chronic hypertensives • If need to increase antihypertension medication in third trimester consider admission to monitor blood pressure and rule out superimposed preeclampsia • Decision to deliver is similar to other preeclamptic women based on gestational age and presence of severe feature

Chapter C Vaginal Bleeding in Late Pregnancy slide 1 Jennifer Frank, MD Pat Fontaine, MD Larry Leeman, MD

Published August 2010 slide 2 OBJECTIVES After completing this chapter, participants will be able to: 1. Identify major causes of vaginal bleeding in the second half of pregnancy. 2. Describe a systematic approach to identifying the cause of bleeding. 3. Describe specific treatment options based on diagnosis.

A 22 year old G3P2 presents to labor and delivery at 28 weeks gestation after having an episode of vaginal bleeding. Initially she noticed a small amount of blood-tinged mucus, but one hour prior to admission she experienced a gush of bright red blood. Her first delivery was a cesarean section for failure to progress at term, and her second was an elective repeat cesarean at 38 weeks.

A 30 year old G1P0 is undergoing oxytocin augmentation at 36 weeks for preeclampsia. Her blood pressure has been as high as 170/110 and she is receiving an intravenous infusion of magnesium sulfate. Her cervix has been 6 cm dilated for one hour and she has begun to complain of pain between contractions. A large amount of vaginal bleeding follows her next cervical check.

What is the cause of the vaginal bleeding in these cases? How acute or dangerous is it? What steps should be taken for diagnosis and management?

Vaginal bleeding after midpregnancy is associated with maternal and fetal risks. In addition to maternal morbidity secondary to acute hemorrhage and operative delivery, the fetus may be compromised by uteroplacental insufficiency, premature birth, and perinatal death.1 Optimal management of late pregnancy bleeding depends on an accurate identification of the cause and a timely intervention specific to its severity. slide 3 CAUSES OF LATE PREGNANCY BLEEDING The four conditions that account for most cases of serious or life-threatening hemorrhage are placenta previa, placental abruption, uterine scar disruption and vasa previa. Non-emergent causes of bleeding include cervical dilatation during normal labor, which is commonly accompanied by a small amount of blood or blood-tinged mucus (bloody show). Many pregnant women experience spotting or minor bleeding after sexual intercourse or a digital vaginal examination. Cervicitis, cervical ectropion, cervical polyps, and cervical cancer are other possible causes of minor bleeding.

— Chapter C: Vaginal Bleeding in Late Pregnancy — 1 The history, physical examination, ultrasonography for placental location, and a brief period of observation usually differentiates minor from serious causes of vaginal bleeding. Evaluation with a sterile speculum examination may be performed safely prior to ultrasonographic evaluation; however, digital examination should not be performed until ultrasonography excludes a placenta previa.2

MANAGEMENT OF ANTEPARTUM HEMORRHAGE Major causes of vaginal bleeding in pregnancy and their risk factors are listed in Table 1. The initial management of significant bleeding in late pregnancy is similar regardless of the etiology. slide 4 Determination of vital signs and assessment for circulatory instability are the first steps, along with establishing intravenous access and beginning prompt fluid resuscitation as indicated. Mild tachycardia is normal in pregnancy, but orthostatic changes in blood pressure or pulse may be significant. Signs and symptoms of shock are late findings in pregnant women and represent a blood loss of over 30 percent of blood volume. Hypotension, tachycardia, and maternal symptoms of hemodynamic instability are ominous indicators, and women with these signs require immediate intravenous fluid resuscitation and the availability of blood products.

A general physical examination and survey for trauma should be performed as indicated by the history. Examination of the maternal abdomen should include assessment of fundal height, estimated fetal weight, and fetal presentation. Location of tenderness should be noted and contractions should be assessed. Visual estimates of blood loss should be recorded but may be inaccurate or fail to account for concealed hemorrhage.

Baseline laboratory tests include hematocrit, platelet count, fibrinogen level, coagulation studies, slide 5 blood type and antibody screen. In some instances, it may be appropriate to obtain pre-eclampsia labs or a urine drug screen. Fibrinogen levels less than 250 mg/dL are abnormal and less than 150 mg/dL are diagnostic for coagulopathy. Protime and activated partial thromboplastin time may be abnormal, and platelet levels may be low. Fibrin split products may be elevated, but the presence of fibrin D-dimer is poorly correlated with the diagnosis of abruption.3 If coagulation studies are not readily available, a serum sample may be drawn and taped to the wall for a simple and inexpensive “clot test.” If no clot or a poor quality clot is present after seven to ten minutes, then coagulopathy is present. Women who are Rh negative should receive Rho(D) immune globulin (Rhogam); a Kleihauer-Betke test should be performed to determine the appropriate dose.4

Continuous fetal monitoring is recommended to determine if there is a need for urgent operative delivery.5 Fetal heart rate decelerations, tachycardia or loss of variability may resolve with adequate maternal resuscitation; however, a persistently nonreassuring fetal heart rate tracing may require delivery before the etiology of the hemorrhage is established.

2 — — Chapter C: Vaginal Bleeding in Late Pregnancy Table 1. Risk Factors for Major Causes of Vaginal Bleeding in Late Pregnancy6

Placenta previa7 Uterine rupture11,12 • Chronic hypertension • Abnormal placentation • Multiparity • History of uterine surgery • Multiple gestations • Maternal connective tissue disease • Older age • Uterine anomalies • Previous cesarean delivery • Trauma • Tobacco use • Trial of labor after cesarean section • Uterine curettage (TOLAC)

Placental abruption8,9,10 Vasa previa13,14 • Chronic hypertension • Fetal anomalies • Multiparity • In vitro fertilization • Preeclampsia • Low-lying and second trimester • Previous abruption placenta previa • Short umbilical cord • Marginal cord insertion • Sudden decompression of an • Multiple gestation overdistended uterus • Succenturiate-lobed and bilobed • Thrombophilias placentas • Tobacco, cocaine, or methamphetamine use • Trauma: blunt abdominal or sudden deceleration • Unexplained elevated maternal alpha fetoprotein level • Uterine fibroids

PLACENTA PREVIA Definitions and Pathophysiology Placenta previa occurs when the placenta implants in a location overlying or in close proximity to slide 6 the internal cervical os.15 The pathophysiology of placenta previa is not fully understood. Normally, placental implantation favors a fundal location. As pregnancy progresses, the apparent “migration” of the placenta away from the lower uterine segment is caused by the growth of placental trophoblasts toward the fundus, with its richer blood supply, and by the development or elongation of the lower uterine segment. Abnormal implantation of the placenta may occur when there is disruption or scarring of the uterine cavity.

Transvaginal ultrasonography allows precise assessment of the distance between the internal os and the placental edge. The placenta is described as a complete previa when it covers the internal os and as a marginal previa when the edge lies within 2 cm of the os. When the edge is 2 to 3.5 cm (1.4 inches) from the os, the placenta may be described as low-lying.16

— Chapter C: Vaginal Bleeding in Late Pregnancy — 3 Epidemiology Placenta previa is a common incidental finding on second trimester ultrasonography, present on slide 7 approximately four percent of ultrasound studies performed at 20 to 25 weeks’ gestation17 but only 0.4 percent of pregnancies at term.7 The likelihood of a previa persisting until term increases if the previa is complete, if it is present at a later gestational age, or if there is a history of cesarean delivery.18 The extent to which the placenta overlaps the internal os at 18 to 23 weeks is highly predictive for the persistence of placenta previa.19,20 If the overlap is less than 1.5 cm (0.6 inches) at 18 to 23 weeks, placenta previa typically resolves;20 if the overlap is 2.5 cm (one inch) or greater at 20 to 23 weeks, persistence to term is likely.19 Routine late pregnancy ultrasound in low-risk or unselected populations does not confer benefit to the mother or baby and may increase cesarean section rates.21

Risk factors associated with placenta previa include chronic hypertension, multiparity, multiple slide 8 gestations, increasing maternal age, previous cesarean delivery, tobacco use, uterine curettage, inadequate prenatal care, and male fetal gender.7,22 The incidence of placenta previa is 2.3 percent among women having their third cesarean delivery.23

Morbidity Maternal morbidity associated with placenta previa can result from maternal hemorrhage, cesar- slide 9 ean delivery, or abnormal placental attachment, specifically, placenta accreta, increta, or percreta. Complete placenta previa is associated with higher morbidity than low-lying or marginal placenta previa.24,25 Exsanguinating maternal hemorrhage rarely occurs unless instrumentation or digital exam is performed.

Women who have had a prior cesarean delivery and have a placenta previa or low anterior placenta slide 10 in a subsequent pregnancy are at increased risk of abnormal placental attachment.26,27 The risk of placenta accreta, increta, or percreta reaches about 10 percent when placenta previa coexists with previous cesarean delivery.28,29 The risk of abnormal placental attachment also increases with the number of previous cesarean deliveries.27 Women with a history of cesarean delivery who present with placenta previa or a placenta located at the site of the previous incision should be evaluated for potential placenta accreta with color-flow Doppler by an experienced sonographer.30,31 Magnetic resonance imaging of the pelvis may help confirm the diagnosis of an invasive placenta and delineate organ involvement in women with a placenta percreta.32 A suspected placenta accreta necessitates preparation for possible cesarean hysterectomy, including appropriate surgical expertise and availability of blood.

Perinatal morbidity and mortality associated with placenta previa are mainly related to the complications of prematurity, since the blood loss comes from the maternal circulation.33 Thus, the management of placenta previa, and timing of delivery, is influenced by gestational age and fetal lung maturity balanced against the degree of hemorrhage and urgency of the maternal condition.

Clinical Presentation Symptomatic placenta previa usually manifests as vaginal bleeding in the late second or third trimes- slide 11 ter, often after sexual intercourse. The bleeding is painless unless labor or placental abruption occurs. A large central previa will typically present with bleeding at 26 to 28 weeks gestation — the so-called “sentinel bleed”. This initial sentinel bleed usually is not sufficient to produce hemodynamic instability or to threaten the fetus in the absence of cervical instrumentation or digital examination.

4 — — Chapter C: Vaginal Bleeding in Late Pregnancy Diagnosis Placenta previa should be suspected in patients who have a persistent malpresentation. A cephalic presentation may be impossible due to the presence of a large placenta filling the pelvis. slide 12,13 The diagnosis of placenta previa is confirmed by ultrasound localization of the placenta. When placenta previa is suspected on transabdominal ultrasonography, transvaginal ultrasonography should be performed.34 Transvaginal ultrasonography is safe to perform35 and is more accurate than transabdominal ultrasonography for localizing the placental edge and the internal os. These structures are obscured by acoustic shadows from the symphysis or the fetus in as many as 50 percent of transabdominal ultrasonograms, and the addition of transvaginal ultrasonography clarifies the diagnosis in 26 percent of cases.34

Knowledge of fetal lie36 and placental position are important prior to operative delivery, since they may affect the choice of uterine incision. Gentle insertion of a speculum to view the vaginal vault and cervix should not result in disruption of a placenta previa.

Management slide 14,15 A Cochrane review found few randomized trials of interventions for placenta previa.37 Outpatient management after an initial period of inpatient observation is appropriate for selected patients who do not have active bleeding and who can rapidly access a hospital with operative labor and delivery services.38 Women with asymptomatic previa in the second trimester can continue normal activities until follow-up ultrasonography is performed at approximately 28 weeks. Women with persistent placenta previa in the third trimester should report any bleeding and abstain from intercourse and use of tampons. When bleeding occurs, women with placenta previa are usually admitted to the hospital for assessment.39

slide 16 Because most neonatal morbidity and mortality associated with placenta previa results from complications of prematurity, the main therapeutic strategy is to prolong pregnancy until fetal lung maturity is achieved.40 Tocolytic agents may be used safely to prolong gestation if vaginal bleeding occurs with preterm contractions.41 Corticosteroids should be administered to women who have bleeding from placenta previa at 24 to 34 weeks’ estimated gestation.42

Cervical cerclage has been proposed as a means of prolonging pregnancies complicated by placenta previa, because bleeding occurs in late pregnancy as the placenta is sheared from a lengthening lower uterine segment and dilating cervix.43 The Cochrane meta-analysis found that cerclage decreased the risk of premature birth before 34 weeks (relative risk = 0.45; 95% confidence interval, 0.23 to 0.87); however, it is recommended that additional studies of cerclage be performed before this clinical practice is introduced.37

slide 17 In women with a complete placenta previa, a cervical length of 31 mm or less measured on transvaginal ultrasound may predict risk of emergency cesarean delivery secondary to massive hemorrhage before 34 weeks.44 For women with a marginal previa, it is recommended that no decision on mode of delivery be made until ultrasonography at 36 weeks.45 Women whose placental edge is 2 cm or more from the internal os at term can expect to deliver vaginally unless heavy bleeding ensues.16 Women whose placenta is located 1 to 2 cm (0.4 to 0.8 inches) from the os may attempt vaginal delivery in a facility capable of moving rapidly to cesarean delivery if necessary, with

— Chapter C: Vaginal Bleeding in Late Pregnancy — 5 approximately 69 percent of these women in one study achieving vaginal delivery without increased hemorrhage.15,16 Women with a nonbleeding placenta previa may have amniocentesis at 36 to 37 weeks to document fetal lung maturity before a scheduled cesarean delivery.40

Indications for operative delivery include the presence of persistent, brisk vaginal bleeding which poses a threat to the stability of the maternal-fetal dyad or any vaginal bleeding in a pregnancy where the fetus is sufficiently mature to be delivered with safety. General anesthesia has been associated with increased intraoperative blood loss and need for blood transfusion. Regional anesthesia appears to be a safe alternative, although it may need to be converted to general anesthesia if surgery is prolonged.31

PLACENTAL ABRUPTION Epidemiology Placental abruption is the separation of the placenta from the uterine wall before delivery. It can slide 18 be partial or complete and can vary in degree. Abruption is the most common cause of serious vaginal bleeding, occurring in one percent of pregnancies.46 The incidence of abruption increased between 1979 and 2001, possibly as a result of rising rates of hypertension and stimulant abuse and increased diagnosis by ultrasonography.9

Risk factors associated with abruption include tobacco, amphetamine, or cocaine use, chronic slide 19 hypertension, preeclampsia, thrombophilias, abdominal trauma, chorioamnionitis, oligohydramnios, premature rupture of membranes, and abruption in a previous pregnancy.8,46 Additional risk factors may include iron deficiency anemia47 and inherited thrombophilias.48

Pathophysiology Placental abruption can be due to varying causes. In some cases abnormalities in placental development and implantation that start in the first trimester lead to specific pathologic changes that in turn lead to abruption.46 With blunt trauma to the abdomen, shearing of the uterine-placenta inter- face leads to placental detachment and hemorrhage that can be overt or retroplacental.49 In one large retrospective study of all injured pregnant women at Level I and Level II trauma centers, 84 percent experienced blunt trauma and 16 percent had penetrating injuries. Placental abruption was the most common complication, occurring in 3.5 percent of injured pregnant women and resulting in over 50 percent rate of intrauterine demise.50 Other etiologies of abruption include vasoconstriction associated with cocaine use46 and sudden uterine decompression after rupture of membranes or delivery of a first twin.10

Prevention The incidence of placental abruption may be decreased by cessation of tobacco, cocaine, or amphetamine use, and appropriate care for hypertensive disorders of pregnancy.46 One trial demonstrated a reduction in the incidence of abruption with intrapartum treatment of preeclampsia using magnesium sulfate.51

Pregnant women involved in severe motor vehicle accidents are at increased risk of abruption and proper restraints are frequently not used due to discomfort.52 Efforts toward designing new restraint systems for pregnant women should also be encouraged.

6 — — Chapter C: Vaginal Bleeding in Late Pregnancy Clinical Presentation slide 20 Placental abruption typically manifests as vaginal bleeding associated with abdominal pain, which may vary from mild cramping to severe pain. Patients with posterior placental abruption may complain of back pain rather than abdominal pain, and patients with abruption due to trauma may experience pain without bleeding (concealed hemorrhage). Concealed placental abruption has been reported to occur in 20 to 63 percent of abruptions.53,54,55,56 While the rates of concealed hemorrhage varies widely and has not been studied in large numbers of women, it is important for the clinician to be aware of a possible, significant abruption in the absence of vaginal bleeding.57

The patient history should include questions regarding trauma (including domestic violence), presence of pain and contractions, rupture of membranes, and assessment of risk factors, including a history of hypertension (or signs and symptoms of pre-eclampsia) and stimulant (cocaine, amphetamines) use.

The bleeding may be bright, dark, or intermixed with amniotic fluid. Blood from concealed hemorrhage is usually dark, having been sequestered behind the membranes. The amount of vaginal bleeding is not indicative of the severity of abruption.46 It may be difficult to determine whether bleeding represents exuberant bloody show or abruption. If bleeding is noted at the time of rupture of membranes, vasa previa should also be considered.

Physical examination and Diagnostic Testing slide 21 Fetal heart tones and uterine activity should be documented by continuous monitoring.5 “Tetanic” contractions may be present and, if measured by an intrauterine pressure catheter, are usually recorded as a high resting tone with superimposed small, frequent contractions. The presence of this finding is significant, as it will often be accompanied by a non-reassuring fetal tracing. slide 22 Ultrasound examination may demonstrate retroplacental clot or hemorrhage; however, acute blood clots and the placenta are hyperechoic on ultrasonography and can be difficult to distinguish from one another.58 Thus the diagnosis of abruption is largely a clinical diagnosis and urgent management should never be delayed for ultrasound confirmation. If mother and fetus are stable, the placental location and appearance, fetal lie and fetal weight estimation may be of assistance in planning care. Ultrasound findings, if present, may include a retroplacental echolucency, abnormal thickening of the placenta, or an abnormally round “torn up” edge of the placenta. Computerized tomography is able to identify placenta abruption, and pregnant patients undergoing CT evaluation following trauma should have careful evaluation of the placenta.

Management slide 23 Because the unpredictable nature of abruption does not allow for controlled trials, management remains empiric. A Cochrane review found no randomized controlled trials assessing interventions for placental abruption that met inclusion criteria.60

Mild Abruption A stable patient with a small partial abruption and a preterm fetus may be managed successfully in a conservative manner. Tocolysis generally is contraindicated except in mild abruption before 34 weeks’ gestation, when it may be used to allow administration of corticosteroids.61

— Chapter C: Vaginal Bleeding in Late Pregnancy — 7 Women experiencing recurrent bleeding attributed to placental separation may be diagnosed as having a chronic abruption. Management will be based on the degree of bleeding and gestational age. When expectant management occurs in the setting of chronic abruption, serial ultrasonography for fetal growth and antepartum surveillance are indicated in the third trimester because of the potential for uteroplacental insufficiency.9

Severe Abruption Initial management includes rapid stabilization of maternal cardiopulmonary status and assessment slide 24 of fetal well-being. Delay can be fatal to the fetus; 30 percent of perinatal deaths in one case series occurred within two hours of admission.62

Maternal stabilization requires monitoring of vital signs and urine output, along with serial evaluation of the hematocrit and coagulation studies to determine whether disseminated intravascular coagulation is present.8 The circulatory status of the patient with abruption should be maintained to permit a margin of reserve. Hourly urine output should be maintained at, or above 30 cc per hour. Hematocrit should be maintained above 30 percent. In patients with pre-eclampsia or other confounding factors, central blood pressure monitoring may assist in the fluid management.

A nonreassuring fetal heart tracing necessitates rapid, usually cesarean, delivery.63,64 A decision- to-delivery interval of 20 minutes or less resulted in improved neonatal outcomes in a case-control study of severe abruption.63 Occasionally, abruption occurs during the second stage, and an operative vaginal delivery may be attempted. Neonatal resuscitation personnel should be available for all deliveries, vaginal or operative.

When fetal death occurs secondary to abruption, vaginal delivery should be the goal.65 Labor should be permitted as long as adequate progress is made and maternal status can be supported. Although labor is often hypertonic with abruption, it may also be hypotonic. Oxytocin augmentation is not contraindicated, but should be utilized judiciously with intrauterine pressure monitoring. Indications for operative delivery with fetal demise include other maternal indications for cesarean delivery, failure of labor progression, and brisk hemorrhage that cannot be compensated for by transfusion. slide 25 Approximately one-third of patients with placental abruption with fetal demise will develop coagulopathy. Coagulopathy is usually not seen in the patient presenting with abruption and a live fetus. Coagulopathy in abruption may be related to two etiologies: consumptive coagulopathy and disseminated intravascular coagulation. Replacement of platelets and fresh-frozen plasma should be administered just prior to operative delivery to provide maximum efficacy. In addition, cryoprecipitate or Factor VIII may be of specific benefit in severe coagulopathy.

Consideration of maternal transfer from a rural site is based on many factors. Patients presenting with abruption and a live fetus are usually not stable for transfer, since operative delivery may be needed on an immediate basis at any time during labor. In this instance, neonatal transfer (rather than maternal-fetal) may be a necessary intervention for the premature or sick newborn. If fetal demise has occurred, a patient who does not have coagulopathy and is hemodynamically stable may be cared for with appropriate resources. Blood bank supply may determine whether or not a patient needs transport to a referral facility.

8 — — Chapter C: Vaginal Bleeding in Late Pregnancy Fetomaternal hemorrhage may occur with rupture of fetal vessels in the placenta. The Kleihauer- Betke test is useful to determine dosage of Rh immunoglobulin in Rh negative patients, but is not useful for the diagnosis of abruption.66,67

UTERINE RUPTURE Epidemiology and Pathophysiology slide 26 Uterine scar disruption spans a spectrum from the occult dehiscence that is discovered at repeat cesarean delivery to complete uterine rupture that requires emergency laparotomy. In complete rupture, the fetus or placenta may be partially or completely extruded from the uterus. In this chapter we will focus only on uterine rupture presenting with third trimester bleeding.

Spontaneous uterine rupture is reported in only 0.03 to 0.08 percent of all delivering women, but in about 0.8 percent of women with a uterine scar from prior surgery.68 Previous cesarean incision is the most common etiology for uterine rupture. Other causes include previous uterine curettage or perforation, inappropriate oxytocin usage, and trauma. slide 27 Conditions that predispose to uterine scar disruption include previous uterine surgery (e.g. myomectomy) that involves the full thickness of the myometrium, congenital uterine anomaly, uterine overdistension, intra-amniotic installation, gestational trophoblastic neoplasia, maternal obesity or adenomy- osis.12 Two or more previous cesarean deliveries and labor induction each increase the incidence of uterine rupture to about 0.9 to 1.8 percent and 0.77 to 2.24 percent respectively.68 Conditions present during delivery that predispose to uterine rupture include fetal anomaly, vigorous uterine pressure, difficult manual removal of the placenta, or abnormalities of placental implantation.12 slide 28 The most common maternal morbidity associated with uterine rupture is hemorrhage and subsequent anemia, requiring blood transfusion. Other morbidities include bladder injury (8.8 percent)69 and hysterectomy which accompanies 14 to 33 percent of uterine ruptures.70 No cases of maternal death from uterine rupture have been reported.70 Both fetal and maternal morbidity are higher in cases of uterine rupture of an unscarred uterus.69

Clinical Presentation slide 29 The classic presentation for symptomatic, significant uterine rupture includes vaginal bleeding, pain, cessation of contractions, absence of fetal heart tones, loss of station, easily palpable fetal parts through the maternal abdomen, and profound maternal tachycardia and hypotension. However, most cases (67 to 70 percent) of uterine rupture initially present with abnormal fetal monitoring.68,69

In a review of 159,456 deliveries, the most frequent finding associated with uterine rupture was a sudden deterioration of the FHR pattern.11 There may be a progression of signs from non-specific, severe variable decelerations, to the characteristic recession of the fetal head or suprapubic bulging. Contractions may show a “stair-step” appearance of gradually decreasing amplitude on tocodynamometry.72

Thirteen percent of uterine ruptures occur outside of the hospital. Patients with a prior uterine scar should be advised to come to the hospital for evaluation of new onset of contractions, abdominal pain, or vaginal bleeding as soon as possible.11 Spontaneous antepartum rupture in nonlaboring women is an extremely rare and is typically associated with identifiable risk factors. In a case series

— Chapter C: Vaginal Bleeding in Late Pregnancy — 9 of women experiencing spontaneous uterine rupture in the second or third trimester, six of seven events (over 13 years) involved placenta previa or percreta and five of the seven uterine ruptures occurred in women with prior cesarean deliveries.72 These findings suggest that prior uterine scar and abnormal placenta both play a role in uterine rupture.73

Management In the case of a sudden change in fetal baseline or the onset of repetitive fetal heart rate decelera- slide 30 tions, the provider should institute intrauterine resuscitation with maternal position change, intravenous fluids, discontinuation of oxytocin, oxygen administration, and consideration for subcutaneous terbutaline. If these measures are not effective then emergent cesarean or operative vaginal delivery may be indicated. Asymptomatic scar disruption may be found at the time of cesarean delivery or palpation of the uterine cavity following vaginal delivery. In the latter case, expectant management is appropriate.

VASA PREVIA Vasa previa is the velamentous insertion of the umbilical cord into the membranes in the lower uterine segment resulting in the presence of fetal vessels between the cervix and presenting part. slide 31 Although it is uncommon (the incidence is one in 1275 to 5000 live births),14 it is important for physicians to be familiar with vasa previa because rapid intervention is essential for fetal survival.13

Epidemiology and Pathophysiology This uncommon cause of severe obstetric hemorrhage usually occurs in pregnancies with a low- lying placenta and velamentous insertion, bipartite placenta, or a placenta with a succenturiate slide 32 lobe.14 The significance of this disorder is that it is the only cause of major obstetric hemorrhage in which blood loss is primarily fetal, thus increasing the urgency of diagnosis. Studies demonstrate a 33 to 100 percent rate of perinatal mortality secondary to vasa previa,13 although antenatal diagnosis is associated with a reduction in the rate of neonatal morbidity and mortality.14 Risk factors for vasa previa include in vitro fertilization, placenta previa, and bilobed and succenturiate-lobed placentas.13,74

Clinical Presentation and Diagnosis [Vasa previa may be detected antenatally on vaginal ultrasound with color-flow Doppler14 However, vasa previa most typically manifests as onset of hemorrhage at the time of amniotomy or spontane- slide 33 ous rupture of membranes. The hemorrhage is fetal blood, and exsanguination can occur rapidly because the average blood volume of a term fetus is approximately 250 mL75 In addition to diagnosis by ultrasound or classic clinical presentation, vasa previa may be diagnosed by MRI, amnios- copy, and intrapartum identification of fetal blood intermixed with vaginal blood.14 Rarely, vessels are palpated in the presenting membranes, prohibiting artificial rupture and vaginal delivery.

If fetal heart tones are reassuring, a blood sample from the vaginal vault may be obtained to check for fetal blood cells or fetal hemoglobin. Both the Kleihauer-Betke test and hemoglobin electropho- slide 34 resis measuring the presence of fetal hemoglobin are sensitive but are too slow to use clinically.14 The Apt test (alkali denaturation test) is faster to perform but is insensitive.14 The Apt test is based on the resistance of fetal hemoglobin to denaturation by alkaline agents and can be performed in the labor and delivery unit.76 Performance of the Apt Test involves obtaining a sample of blood from the vagina and then mixing it with a small amount of tap water to lyse the red blood cells. After five minutes of centrifugation, the supernatant is removed and mixed with one mL of one percent NaOH

10 — — Chapter C: Vaginal Bleeding in Late Pregnancy for every 5 mL’s of supernatant. A pink color indicates fetal hemoglobin. Adult hemoglobin is brown. Additionally, a Wright stain of blood collected from the vagina can be evaluated for the presence of nucleated RBCs, which are common in fetal blood but uncommon in adult blood. This test can be performed without delay, assuming a stable fetal heart rate.

Management Delivery should not be deferred for confirmation of fetal blood in women with severe hemorrhage slide 34 or when fetal heart tones are nonreassuring. If the onset of vaginal bleeding occurred with rupture of membranes, and the fetal heart rate is not reassuring, cesarean delivery should be performed immediately. Since fetal exsanguination is the cause of mortality in this disorder, preparation for resuscitation at the delivery includes availability of normal saline at 10 to 20 cc/kg bolus to administer if the newborn is in shock.

Neonatal survival rates with antenatal diagnosis are 97 percent compared with a 44 percent neonatal survival rate without antenatal diagnosis.13,14 In the presence of antenatal diagnosis of vasa pre- slide 35 via, serial ultrasounds are recommended to evaluate for regression of vessels, which can occur in approximately 15 percent of women.14 With persistent vasa previa, hospitalization at 30 to 32 weeks should be considered, which allows for the administration of corticosteroids to promote fetal lung maturity and for proximity to operative delivery if membranes rupture.14 Outpatient management can be considered for asymptomatic women with no uterine activity and a long, closed cervix on transvaginal ultrasound.14 The optimal gestational age for delivery is not determined, but cesarean section delivery at 35 to 36 weeks has been recommended to balance the risk of respiratory distress syndrome with risk of membrane rupture and fetal exsanguination.14

Prevention There are no strategies for primary prevention of vasa previa; however, hemorrhage theoretically is preventable with antenatal screening for women at high risk and cesarean delivery at 35 to 36 weeks when vasa previa is present. Screening is carried out with transvaginal color-flow Doppler to identify the presence of vessels in the fetal membranes. Screening in a general population has not been recommended because the condition is rare (one diagnosis per 5,215 screenings).77 Screening is recommended for women at increased risk78 including after the detection of a low lying, bilobed or succenturiate-lobed placenta on a routine ultrasound or in women who are pregnant following IVF.14 Careful evaluation of the placenta including site of cord insertion on routine ultrasound may facilitate identifying women at greater risk for vasa previa.

SUMMARY Vaginal bleeding in late pregnancy may occur due to potentially life threatening conditions for slide 36 mother and neonate. Providers need to distinguish emergent causes of bleeding from those that are less urgent; to avoid vaginal examination when placental location is unknown; and to act with clarity of purpose and stunning rapidity in the setting of severe hemorrhage or probable vasa previa. The timely diagnosis of vaginal bleeding in late pregnancy, including antenatal diagnosis with color-flow ultrasound, can reduce perinatal mortality. This chapter identified major causes of vaginal bleeding in the second half of pregnancy; described a systematic approach to identifying the cause of bleeding; and identified the appropriate management of the unstable woman with late vaginal bleeding. Institutional policies should be in place to ensure adequate blood bank response to massive hemorrhage, and to mobilize resources for emergent cesarean delivery.

— Chapter C: Vaginal Bleeding in Late Pregnancy — 11 SUMMARY TABLE OF RECOMMENDATIONS Category A Placenta previa is a common incidental finding on second trimester ultrasonography and should be confirmed in the third trimester. Outpatient management of placenta previa is appropriate in selected patients who do not have active bleeding and who can rapidly access a hospital with operative labor and delivery services. Corticosteroids should be administered to women who have bleeding from placenta previa at 24 to 34 weeks gestation. Treatment of preeclampsia with magnesium sulfate decreases the risk of placental abruption and improves maternal outcomes.

Category B Delivery in pregnancies complicated by placenta previa may be safely delayed by the use of tocolytics. Transvaginal ultrasonography may be safely performed in women who have a placenta previa and is more accurate in detecting placental location than transabdominal ultrasonography. In patients presenting with abruption, a decision-to-delivery interval of 20 minutes or less results in improved neonatal outcomes.

Category C A sterile speculum examination can be performed safely in women with second or third trimester vaginal bleeding before ultrasonographic evaluation of placental localization, but a digital examination should be avoided until placenta previa is excluded by ultrasonography. Women with bleeding in late pregnancy who are Rh negative should receive Rho(D) immune globulin (Rhogam) after performance of a Kleihauer-Betke test to determine appropriate dose. In women with placenta previa, imaging with color flow Doppler ultrasonography should be performed to evaluate for placenta accreta. Magnetic resonance imaging of the pelvis may help confirm a diagnosis of invasive placenta and identify organ involvement associated with placenta percreta. Reducing fetal mortality in the presence of vasa previa depends on antenatal diagnosis and delivery by cesarean section. Ultrasound and color Doppler screening for vasa previa is recommended in women at increased risk including women who are pregnant following IVF, when a low lying placenta is detected on second trimester ultrasound, and in the presence of low or velamentous cord insertion, bilobate, or succenturiate placenta.

12 — — Chapter C: Vaginal Bleeding in Late Pregnancy REFERENCES

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Ghi T, Contro E, Martina T, Piva M, Morandi R, Orsini LF, Meriggiola MC, Pilu C, Morselli-Labate AM, et al. 62. Knab DR. Abruptio placentae: an assessment of Cervical length and risk of antepartum bleeding in the time and method of delivery. Obstet Gynecol women with complete placenta previa. Ultrasound 1978;52:625-9. Obstet Gynecol 2009;33:209-12. 63. Kayani SI, Walkinshaw SA, Preston C. Pregnancy 45. National Collaborating Center for Women’s and outcome in severe placental abruption. BJOG Children’s Health. Antenatal care: routine care for the 2003;110:679-83. healthy pregnant woman. Clinical Guideline. London: 64. Witlin AG, Sibai BM. Perinatal and maternal outcome RCOG, 2003. following abruption placentae. Hypertens Pregnancy 46. Oyelese Y, Ananth CV. Placental abruption. Obstet 2001;20:195-203. Gynecol 2006;108:1005-16. 65. Burton R, Belfort MA. Etiology and management 47. Arnold DL, Williams MA, Miller RS, Qiu C, Sorensen of hemorrhage. In: Dildy GA, Belfort MA, Saede TK. Iron deficiency anemia, cigarette smoking and GR, Phelan JP, Hankins GD, Clark SL, eds. Critical risk of abruption placentae. J Obstet Gynecol Res Care Obstetrics. 4th ed. Malden, Mass.: Blackwell 2009;35:446-52. Science, 2004:298-311.

14 — — Chapter C: Vaginal Bleeding in Late Pregnancy 66. Emery CI, Morway LF, Chung-Park M, Wyatt-Ashmead J, Sawady J, Beddow TD. The Kleihauer-Betke test. Clinical utility, indication, and correlation in patients with placental abruption and cocaine use. Arch Pathol Lab Med 1995;119:1032-7. 67. ACOG Update: Major and minor trauma in pregnancy. Vol. 35, No. 6 December 2009 Medical Information Systems Inc. 2 Seaview Blvd. Port Washington, New York. http://www.acogupdate.com/ 68. ACOG Committee on Practice Bulletins. Vaginal birth after previous cesarean delivery. ACOG Practice Bulletin No. 115, August 2010. Obstet Gynecol 2010;116:450-463. 69. Zwart JJ, Richters JM, Ory F, de Vries JIP, Bloemenkamp KWM, van Roosmalen J. Uterine rupture in the Netherlands: a nationwide population based-cohort study. BJOG 2009;116:1069-80. 70. National Institutes of Health Consensus Development Conference Panel. National Institutes of Health Consensus Development conference statement: vaginal birth after cesarean: new insights March 8-10, 2010. Obstet Gynecol 2010;115:1279-95. 71. Matsuo K, Scanlon JT, Atlas RO, Kopelman JN. Staircase sign: a newly described uterine contraction pattern seen in rupture of unscarred gravid uterus. J Obstet Gynaecol Res 2008;34:100–4. 72. Vaknin Z, Maymon R, Mendlovic S, Barel O, Herman A, Sherman D. Clinical, sonographic, and epidemio- logic features of second- and early third-trimester spontaneouos antepartum uterine rupture: a cohort study. Prenat Diagn 2008;28:478-84. 73. Jauregui I, Kirkendall C, Ahn MO, Phelan J. Uterine rupture: a placentally mediated event? Obstet Gynecol 2000;95(Suppl1):S75. 74. Baulies S, Maiz N, Torrents M, Echevarria M, Serra B. Prenatal ultrasound diagnosis of vasa previa and analysis of risk factors. Prenat Diagn 2007;27:595-9. 75. Nelle M, Zilow EP, Kraus M, Bastert G, Linderkamp O. The effect of Leboyer delivery on blood viscosity and other hemorrheologic parameters in term neonates. Am J Obstet Gynecol 1993;169:189-93. 76. Apt L, Downey WS Jr. Melena neonatorum: the swal- lowed blood syndrome; a simple test for the differen- tiation of adult and fetal hemoglobin in bloody stools. J Pediatr 1955;47:6-12. 77. Lee W, Lee VL, Kirk JS, Sloan CT, Smith RS, Comstock CH. Vasa previa: prenatal diagnosis, natural evolution, and clinical outcome. Obstet Gynecol 2000;5:572-6. 78. Oyelese Y, Catanzarite V, Prefumo F, Lashley S, Schachter M, Tovbin Y, et al. Vasa previa: the impact of prenatal diagnosis on outcomes. Obstet Gynecol 2004;103:937-42.

— Chapter C: Vaginal Bleeding in Late Pregnancy — 15 Chapter D Preterm Labor & Premature Rupture of Membranes slide 1 William Sayres, MD

Published June 2011

OBJECTIVES slide 2 After completing this chapter, participants will be able to: • Define preterm labor (PTL) and premature rupture of membranes (PROM) and describe their significance. • List risk factors associated with PTL and PROM. • Outline initial evaluation of PTL and PROM. • Describe management of PTL and PROM. • Discuss neonatal group B streptococcal (GBS) prevention strategies.

INTRODUCTION Previous preterm delivery (PTD) is the most important historical risk factor for subsequent PTD. Other important antenatal risk factors include multiple gestation, bacterial vaginosis, and short cervix. In a patient presenting with preterm contractions, cervical length on transvaginal ultrasound or a fetal fibronectin test can be used to help assess the risk of preterm delivery. Progesterone may be used to decrease the likelihood of preterm delivery in patients with a prior preterm delivery or a short cervical length on ultrasound. Administration of antenatal corticosteroids remains our most important intervention to improve perinatal outcomes in women presenting with preterm labor (PTL). Tocolytic agents may delay preterm delivery allowing time to administer steroids or transfer to facilities with a Neonatal Intensive Care Unit (NICU). Management of preterm premature rupture of membranes (PPROM) may include administering antibiotics, antenatal corticosteroids, or labor induction based on the gestational age at presentation. Management of premature rupture of membranes (PROM) at term includes early induction/augmentation of labor. slide 3 EPIDEMIOLOGY The United States’ incidence of preterm delivery (PTD), defined as occurring before 37 weeks’ gestation, was 12.3 percent in 2008.1 About 40 to 45 percent of preterm deliveries are the result of spontaneous preterm labor with intact membranes. Twenty-five to 30 percent are associated with preterm premature rupture of the membranes. The remaining 30 to 35 percent of preterm deliveries are the result of delivery by labor induction or cesarean section for medical indications such as severe preeclampsia, placental abruption, or intrauterine growth restriction.2 slide 4 The incidence of PTD increased 20 percent from 1990 to 2006. This increase has been associated with a rise in multiple gestations and increased indicated late preterm deliveries (between 34 and 36 weeks’ gestation). The rate has fallen from 12.8 percent in 2006 to 12.3 percent in 2008; perhaps due to efforts to decrease the proportion of elective inductions and cesarean deliveries occurring

— Chapter D: Preterm Labor & Premature Rupture of Membranes — 1 before 37 weeks.1 The use of assisted reproductive technology (ART) has resulted in an increase in multiple gestations; singleton pregnancies conceived with ART are also associated with shorter gestations.3 Although infant mortality rates increase significantly below 32 weeks,4 late preterm delivery, defined as 34 to 36 weeks’ gestation, is nevertheless responsible for significant morbidity, including the majority of NICU admissions.5 Despite the increase in the rate of PTD, the rates of infant and neonatal mortality in the US have fallen steadily.4 At least some of the continuing decrease in perinatal mortality may be attributed to medically indicated preterm delivery.6

RISK FACTORS FOR PTD Up to 50 percent of extremely preterm deliveries occur in pregnancies with no known risk factors.7

Maternal characteristics: African-American race is associated with increased rates of PTD and of slide 5 extreme PTD in particular.1 Short interpregnancy interval (< six months) increases the risk of PTD by 1.4 (95%CI 1.24 to 1.58).8 Maternal nutritional status and, in particular, pre-pregnancy body mass index (BMI) of < 20 increases the odds of PTD by 3.96.9 Pregnancies, both multiple and single gestations, resulting from assisted reproductive technology have higher rates of PTD.10

Maternal psychological and social stress, physically strenuous work and lack of social support have been related to PTD.2 Physical abuse was associated in one study with an overall risk (OR) for PTD of 3.14 (CI 2.00 to 4.93).11 Maternal exposure to environmental pollutants such as tobacco smoke and lead, as well as to air pollution, increases the risk of PTD.12 Maternal cigarette smoking has a modest association with PTD; smoking 10 to 20 cigarettes has a relative risk (RR) of 1.2 to 1.5 and more than 20 cigarettes per day a relative risk of 1.5 to 2.0.13 Smoking has a dose-dependent effect on incidence of PTD as well as gestational age at delivery.14 History of cervical cone biopsy or loop electrosurgical excision procedure for cervical intraepithelial neoplasia increases the relative risk for PPROM by 2.7 to 1.9 respectively.15

History of preterm delivery is the most important identifiable risk factor for recurrent PTD and defines a high-risk pregnancy in the majority of research on preventive interventions. In general the risk is increased by a factor of 2.5. Risk increases with shorter penultimate gestations and number of previous preterm deliveries.16,17 Women with a prior indicated preterm delivery are not only at increased risk for a subsequent indicated PTD, but also for subsequent spontaneous PTD.18 Multiple gestation is one of the strongest predictors for preterm delivery with the majority of twin pregnancies delivering less than 37 weeks due to spontaneous preterm labor and medical indications for delivery.19 Twelve percent of twin, 36 percent of triplet and 60 percent of quadruplet pregnancies will deliver prior to 32 weeks.20

Inflammation is one of the primary etiologic pathways to preterm labor (PTL). Infection may be the cause of the majority of extremely preterm deliveries.21 Bacterial vaginosis (BV) increases the risk of PTD (OR 2.19; 95% CI 1.54 to 3.12) and spontaneous abortion (OR 9.91; 95% CI 1.99 to 49.34). Women screened and found positive for BV at less than 16 weeks’ gestation had an even higher likelihood of PTD (OR 7.55; 95% CI 1.80 to 31.65).22 Asymptomatic bacteriuria, possibly as a precursor to pyelonephritis, increases risk for PTD.23 Sexually transmitted infections such as chlamydia, gonorrhea, and syphilis are all associated with increased risk for PTD.2 Non-genitourinary infection has also been linked to subsequent preterm delivery. Periodontal infection doubles the risk for PTD.24

2 — — Chapter D: Preterm Labor & Premature Rupture of Membranes Genital Mycoplasma spp and Ureaplasma urealyticum are the most commonly identified microor- ganisms in the amniotic cavity in women having preterm labor.2 Organisms theoretically ascend from the vagina and cervix before 20 weeks’ gestation when membranes become tightly applied to decidua.2 Inflammatory mediators (such as cytokines and TNF-alpha) may play a role in initiating labor. Some women may be genetically predisposed to PTD associated with infection. The TNF- alpha allele 2 gene, for instance, doubles the risk of PTD associated with BV.25 slide 6 Uterine contractions increase the likelihood of Figure 1. Measurement of Cervical Length preterm delivery. In a study of 306 women with 34,908 hours of monitoring, increased uterine contractions were associated with preterm delivery; however, there was not a threshold frequency of contractions that effectively identified a high-risk group.26

Short cervical length and funneling of the cervix on ultrasound indicate increased risk for preterm delivery. Proper technique for ultra- Measurements before 14 weeks lack predictive sonic cervical measurement is described in value. Prognostic usefulness is limited after 32 several papers.27,28 Figure 1 demonstrates the weeks, at which point cervical effacement begins in normal pregnancies.28 ultrasonic parameters as depicted by Iams.27

Figure 2. Cervical Length and Relative Risk of Preterm Delivery

Figure 2 summarizes findings from a study of cervical lengths of 2915 women at 24 weeks’ gestation. The bars represent relative risk of PTD before 35 weeks for a given cervical length. The bell-shaped graph reflects the distribution of cervical lengths. Relative risk of PTD increases as the cervical length shortens. In general, a short cervix is considered less than 30mm.29 Copyright permission obtained by the Massachusetts Medical Society, publishers of the New England Journal of Medicine.

— Chapter D: Preterm Labor & Premature Rupture of Membranes — 3 Figure 3. Sensitivity, Specificity, Positive and Negative Predictive Values of Ultrasound Cervical Length Measured at 24 and 28 Weeks in Asymptomatic Low-risk Patients for Delivery at Less than 35 Weeks29 Cervix at 24 weeks Cervix at 28 weeks (incidence of PTD at < 35 weeks 4.3 percent) (incidence of PTD at < 35 weeks 3.3 percent)

Cervical Length (mm) < 20 < 25 < 30 < 20 < 25 < 30

Positive Predictive 25.7 17.8 9.3 16.7 11.3 7.0 Value (%) Negative Predictive 96.5 97.0 97.4 97.6 98.0 98.5 Value (%)

Table 1. Risk Factors for Preterm Delivery (PTD)

• African-American race • Interpregnancy interval < 6 months • Low pre-pregnancy BMI • History of PTD • Multiple gestation • Vaginal bleeding caused by placental abruption or placenta previa • Polyhydramnios or oligohydramnios • Maternal abdominal surgery • Maternal medical disorders • History of cervical cone biopsy or LEEP • Uterine anomalies • Maternal psychological or social stress • Smoking • Cocaine or amphetamine use • Infection: – Intrauterine – Bacterial Vaginosis – Chlamydia – Trichomonas – Periodontal disease • Uterine contractions • Short cervix

4 — — Chapter D: Preterm Labor & Premature Rupture of Membranes PREVENTION OF PTD slide 7 Prevention of PTD has been the focus of intense research for the last several decades. Antenatal progesterone has shown promise in recent trials. Screening and treatment of bacterial vaginosis has been less successful historically, although better results are apparent with earlier screening, better choice of subjects and choice of antibiotic. Cervical cerclage continues to be used in certain populations.

ANTENATAL PROGESTERONE The mechanisms by which progesterone prevents PTL include reduction of gap junction formation, oxytocin antagonism, maintenance of cervical integrity and anti-inflammation.30

In women with a history of PTD, antenatal progesterone reduced the risk of subsequent PTD at both < 37 and < 34 weeks,31,32 although these results are tempered by one large study which did not demonstrate improvement in pregnancy outcome.31 One study demonstrated decreased rates of neonatal necrotizing enterocolitis, intraventricular hemorrhage and need for supplemental oxygen.33 A meta-analysis supports the benefit of progesterone supplementation in decreasing the likelihood of preterm delivery in high-risk women with a relative risk of birth at < 34 weeks of 0.15, and at < 37 weeks 0.8.32 In normal-risk women at a median of 22 weeks’ gestation with a cervical length of < 15 mm, treatment with vaginal progesterone was associated with a relative risk of 0.56 for delivery before 34 weeks.34 Progesterone does not improve the outcome in twin pregnancy.35

Table 2. Progesterone Formulation and Dosage for the Prevention of PTD36

Formulation Dosing Indication

17 alpha-hydoxyprogesterone caproate 250 mg IM weekly from Prior preterm delivery33 16 to 20 weeks through 36 weeks Progesterone capsule 100 mg vaginally HS Prior preterm delivery37 from 24 to 34 weeks Progesterone capsule 200 mg vaginally HS Cervical length < 15 mm34 from 20 to 34 weeks

A meta-analysis demonstrated 0.29 RR of PTD < 37 weeks’ gestation and 0.30 RR of neonatal respiratory distress syndrome. The American College of Obstetricians and Gynecologists recommends that progesterone supplementation be offered to patients with a history of PTD as well as for those with serendipitously noted ultrasonic cervical length < 15 mm.38 slide 8 TREATMENT OF INFECTION Screening for bacterial vaginosis (BV) in asymptomatic low-risk women remains controversial. Three studies screened asymptomatic, low-risk women for BV early in the second trimester and treated with clindamycin (vaginally in two and orally in one). In all three studies, the treated women had lower rates of PTD and also less late second-trimester miscarriages.39,40,41 A Cochrane analysis based on only one of the above studies concluded that screening and treating asymptomatic women for lower genital tract infections reduced the incidence of delivery before 37 weeks.41 In contrast, the U.S. Preventive Services Task Force recommends against screening for BV in low-risk women and concludes that evidence is insufficient to recommend for or against screening for and treating BV in high-risk patients.42

— Chapter D: Preterm Labor & Premature Rupture of Membranes — 5 Although most studies use criteria based on gram stain, most clinicians will rely on Amsel’s43 criteria for diagnosis of BV.

Table 3. Amsel’s Criteria for Diagnosis of Bacterial Vaginosis slides 9

Diagnosis requires three of four findings

Homogenous, white, non-inflammatory discharge that smoothly coats the vaginal walls

Presence of clue cells on microscopic examination

pH of vaginal fluid > 4.5

Fishy odor of vaginal discharge before or after addition of 10 percent KOH

Clindamycin was used for the treatments of bacterial vaginosis in the three studies cited above with either 300 mg by mouth twice daily for five to seven days or two percent vaginal cream nightly for three to six days. Vaginal clindamycin treatment is not included in the recommended treatment regimes from CDC listed below.

Table 4. CDC Recommendations for Treatment of Bacterial Vaginosis in Pregnancy44 Metronidazole 500 mg orally twice a day for seven days

Metronidazole 250 mg orally three times a day for seven days

Clindamycin 300 mg orally twice a day for seven days

CERVICAL CERCLAGE Although premature cervical change might be the result of a structurally weak cervix, shortening might also be the result of endocrine, paracrine or inflammatory processes.30 Infection, for example, is associated with up to 51 percent of patients presenting with cervical insufficiency.25 Cerclage specifically addresses structural deficits in the cervix and would not necessarily be as effective for other processes such as infection. Meta-analysis of 2175 patients given prophylactic cervical cerclage demonstrated a small reduction in births under 33 weeks’ gestation, and was associated with mild pyrexia, increased use of tocolysis and hospital admissions and did not improve neonatal outcomes.45

SMOKING CESSATION, ASYMPTOMATIC BACTERIURIA AND OTHER INTERVENTIONS FOR THE PREVENTION OF PTD In a large observational study in Sweden, women with a previous preterm delivery and who smoked during that pregnancy had a decreased risk of subsequent PTD if they did not smoke.14 Smoking cessation programs reduce the relative risk of PTD (0.84 CI 0.72 to 0.98).46 Interventions for smoking cessation are not equally effective, nor are they always transferrable to different settings. Programs using rewards plus social support were most effective.46

Although associated with PTD, screening for and treating asymptomatic bacteriuria did not reduce the incidence of PTD. Incidences of pyelonephritis and low birth weight were decreased.13

Risk of PTD is not improved with regular nursing contact,47 periodontal care,48 or nutritional supplementation.49

6 — — Chapter D: Preterm Labor & Premature Rupture of Membranes ASSESSMENT OF THE SYMPTOMATIC PATIENT The following section describes initial assessment of the patient presenting with premature contractions. Goals include assessment for rupture of membranes, assessment for infection, determination of likelihood of preterm delivery. A protocol for evaluation is listed below.

Table 5. Assessment of the Patient Presenting with Premature Contractions slide 10 Are the membranes History ruptured? Leakage of fluid from cervical os on sterile speculum exam Nitrazine reaction of fluid Ferning of fluid Ultrasound for oligohydramnios Amnioinfusion of indigo carmine (if above tests are nondiagnostic) Is infections present? Group B Streptococcus carrier status Sexually transmitted infection status Urinary tract infection Chorioamnionitis, possibly subclinical What is the likelihood that Single-dose terbutaline the patient will delivery Fetal fibronectin prematurely? Ultrasound cervical length slide 11 ARE THE MEMBRANES RUPTURED? Sterile speculum assists in evaluation of membrane integrity and facilitates collection of fetal fibronectin (fFN) sample. Direct observation of amniotic fluid leaking from the cervical os is diagnostic of ruptured membranes. Gentle fundal pressure or having the patient cough during the exam may facilitate leakage. Prolonged recumbence of the patient suspected to have ruptured membranes may lead to pooling of fluid in the vaginal vault.50 Amniotic fluid when allowed to air dry on a slide will demonstrate ferning or arborization. A false-positive test for ferning is possible if cervical mucous is inadvertently tested. The pH of the normal vaginal environment is 4.5 to 6.0 whereas the pH of amniotic fluid is 7.1 to 7.3 and will change the color of nitrazine paper from orange to blue. Accuracy of the ferning test for diagnosis of ruptured membranes is 84 to 100 percent and the nitrazine reaction 87 to 97 percent.51 Rupture of membranes may be diagnosed with a rapid slide test for placental alpha microglobulin-1 protein in cervicovaginal discharge. Two studies of 20352 and 18453 patients demonstrated strong performance as noted in Table 6 below.

Table 6. Performance of Placental Alpha Microglobulin-1 Protein Assay in Diagnosis of ROM Positive Predictive Negative Predictive Study Sensitivity Specificity Value Value Cousins et al. 98.9 percent 100 percent 100 percent 99.1 percent (n=203)52 Park et al. 98.7 percent 87.5 percent 98.1 percent 91.3 percent (n=184)53

Oligohydramnios on ultrasound supports diagnosis of rupture of membranes.50

— Chapter D: Preterm Labor & Premature Rupture of Membranes — 7 IS INFECTION PRESENT? slide 12 A high index of suspicion for infection is reasonable given the close association with PTD. Evaluate prematurely contracting patients for sexually transmitted infections, urinary tract infection and bacterial vaginosis. Unless recently tested for GBS, take a vaginal/rectal culture. Subclinical chorioamnionitis, infection without the classic findings of fever, uterine tenderness, foul-smelling discharge and maternal tachycardia, may be present.54

WHAT IS THE LIKELIHOOD OF PTD? slide 13 The classic definition of labor is regular uterine contractions accompanied by the descent of the fetal presenting part and progressive dilatation and effacement of the cervix. Labor may also be defined as cervical effacement of 80 percent, or dilatation of 2 cm in the presence of regular uterine contractions. Use of regular uterine contractions as the sole criterion for diagnosis is associated with a 40 to 70 percent false-positive rate.55 In one observational study, 38 percent of women presenting to Labor and Delivery with preterm contractions went on to deliver during that admission.56 Early diagnosis of preterm labor, in spite of these difficulties, increases the ability to transfer a laboring mother to a facility with a neonatal intensive care unit, administer glucocorticoids and initiate prophylactic treatment of GBS.27

Triaging tools available to the clinician include a single dose of subcutaneous terbutaline, the fetal slide 14 fibronectin (fFN) test and cervical ultrasound. Abolishment of contractions with a single subcutaneous 0.25 mg dose of terbutaline decreased time to discharge from five to four hours when compared to observation alone.57

Fetal fibronectin testing is most useful for its negative predictive value and may be used between 24 slide 15 and 34 weeks’ gestation. Oncofetal fibronectin is a placental glycoprotein and a major component of the chorio-decidual extracellular matrix. The negative predictive value of the fFN assay is greater than 99 percent for delivery within 14 days. The positive predictive value is 13 to 30 percent for delivery in seven to ten days for symptomatic patients.58 The test should not be performed when there is active vaginal bleeding, or when intercourse, digital vaginal examination, or endovaginal ultrasound has occurred in the preceding 24 hours as these can yield a false positive test result.59

Although large prospective studies are not available, in one study only one patient out of 335 with slide 16,17 a cervical length > 30 mm delivered within seven days.60 In patients presenting with preterm contractions, an ultrasound cervical length of > 30 mm would rule out PTL.27 Establishing a threshold cervical length at which a patient is at increased risk is more problematic.61 Table 7 demonstrates likelihood of delivery at different cervical lengths stratified by fFN result. Cervical length < 15 mm indicates high likelihood of PTD regardless of fFN result. In the ‘grey zone’ of 15 to 30 mm, fFN result has a much greater impact on likelihood of delivery and therefore is more useful in decision-making.62

8 — — Chapter D: Preterm Labor & Premature Rupture of Membranes Table 7. Use of fFN result on Likelihood of Delivery Within Seven Days at Different Ultrasound Cervical Lengths62 Cervical Length (mm) fFN Delivery Within seven days

> 30 mm + 7.1 percent

> 30 mm – 2.2 percent

> 15 mm, < 30 mm + 22 percent

> 15 mm, < 30 mm – 5 percent

< 15 mm + 75 percent

< 15 mm – 36 percent

MANAGEMENT OF PRETERM LABOR slide 18 Once preterm labor has been diagnosed, only three antenatal interventions have been demonstrated to improve outcome: delivery at a facility with a level III nursery, administration of corticosteroids and antibiotic prophylaxis of neonatal group B streptococcal infection. slide 19 ANTENATAL CORTICOSTEROID (ACS) TREATMENT Treatment with antenatal corticosteroids decreases neonatal death and morbidity as listed in the table below.63

Table 8. Effect of ACS on Fetal Outcomes in PTL63 Outcome RR (95 percent CI)

Neonatal death 0.69 (0.58 to 0.81)

Respiratory distress syndrome 0.66 (0.59 to 0.73)

Intraventricular hemorrhage 0.54 (0.43 to 0.69)

Necrotizing enterocolitis 0.46 (0.29 to 0.74)

Respiratory support, intensive care admissions 0.80 (0.65 to 0.99)

Systemic infections in the first 48 hours of life 0.56 (0.38 to 0.85)

Treatment with antenatal corticosteroids does not increase risk of maternal death, chorioamnionitis or puerperal sepsis.63 Antenatal corticosteroid use is effective in women with premature rupture of membranes and pregnancy-related hypertension syndromes.63 A single course is recommended between 24 and 34 weeks; gestation.64 The optimal effects of ACS appear to wane after a week; however, the use of repeat courses for women who remain undelivered and at risk for PTD remains controversial due to possible adverse neonatal effects of repeat courses.65 A single ‘rescue course’ of ACS prior to 33 weeks’ gestation improved fetal respiratory outcomes in one study.66 Other studies have not demonstrated improved outcomes with weekly courses of ACS67 while showing an increase in cerebral palsy at two to three years of age.68 Doses of corticosteroids are noted on the next page.

— Chapter D: Preterm Labor & Premature Rupture of Membranes — 9 Table 9. Antenatal Corticosteroids for Fetal Maturation

Corticosteroid Dosage

Betamethasone Two doses of 12 mg IM twice given 24 hours apart

Dexamethasone Four doses of 6 mg given IM every six hours63

TOCOLYSIS slide 20 The goal of tocolysis is to delay delivery to allow time for maternal transfer if necessary, ACS and neonatal GBS prophylaxis. Since preterm labor may be the result of infection, decidual thrombosis, or physiologic stress leading to activation of the fetal adrenal axis, prolongation of the pregnancy may be prolonging fetal exposure to a potentially hostile environment.30

Nifedipine decreases the likelihood of delivering within seven days (RR 0.76; 95 % CI 0.60 to 0.97) and before 34 weeks (RR 0.83; 95% CI 0.69 to 0.99). Fetal outcomes (respiratory distress syndrome (RR 0.63; 95% CI 0.46 to 0.88), necrotizing enterocolitis (RR 0.21; 95% CI 0.05 to 0.96), and intraventricular hemorrhage (RR 0.59; 95% CI 0.36 to 0.98) are improved and maternal side effects are minimal.69 Following cessation of labor, maintenance therapy (based on one trial) does not improve outcome.70 Meta-analysis of randomized trials demonstrates that betamimetics are effective in delaying delivery for 48 hours. Fetal outcomes were not improved in this analysis. Maternal side effects were significant. Fetal tachycardia was also noted.71 In 2011, the FDA warned against using terbutaline for over 48 to 72 hours for treatment of preterm labor or any use of oral terbutaline to prevent preterm labor.

Nonsteroidal anti-inflammatory drugs (NSAIDs) increase the likelihood of delivery at > 37 weeks and average gestational age at delivery (weighted mean difference 3.53 weeks) with low maternal side effects.72 Early concerns about potential neonatal side effects from indomethacin73 are allayed by a subsequent meta-analysis and may be related to the role of infection, especially in very preterm labor.74 According to one decision analysis, prostaglandin inhibitors may be the optimal first line agent for preterm labor before 32 weeks’ gestation.75 Another consideration might be the presence of polyhydramnios, in which case prostaglandin inhibitors would be expected to decrease amniotic fluid volume. Because of risk of premature closure of the ductus arteriosus, NSAIDs should not be used for more than 48 hours.76

In spite of widespread use77 and a theoretical basis for therapeutic effect, studies of magnesium sulfate for tocolysis fail to demonstrate either prolongation of pregnancy for 48 hours nor improvements in fetal outcome.78,79 The Cochrane analysis found magnesium sulfate for tocolysis to be ineffective. The risk of death (fetal and pediatric) was higher for infants exposed to magnesium sulfate (RR 2.82; 95% CI 1.2 to 6.6) based on seven trials (n=727).79 Placebo controlled trials show lack of effect and trials controlled with other classes of tocolytics (including CCBs) show no differences in outcome.78,79 Several trials of neuroprotection have demonstrated that magnesium sulfate administered before delivery may decrease incidence of cerebral palsy (CP) without affecting neonatal mortality.80 A meta-analysis of trials calculated a RR of 0.69 (95% CI 0.55 to 0.91) with a number needed to treat to prevent one case of CP of 63 (95% CI 43 to 155).81 Dosage regimes varied between individual studies; the regime used by Rouse et al is a 6-gram intravenous bolus followed by constant infusion of 2 grams per hour until delivery or for 12 hours maximum.82

If MgSO4 is to be used for neuroprotection in PTL, physicians and hospitals should develop specific guidelines for use based on these studies.80

10 — — Chapter D: Preterm Labor & Premature Rupture of Membranes Table 10. Pharmaceutical Agents for Tocolysis

Drug (Class) Dosage Comment Contraindications and Side Effects

Magnesium 4 to 6 gm In widespread use in Contraindication: Myasthenia gravis sulfate bolus over the United States, meta- slide 21 Maternal side effects: Flushing, lethargy, head- 20 minutes, analysis fails to demonstrate ache, muscle weakness, diplopia, dry mouth, then 1 to improvement in outcomes. pulmonary edema, cardia arrest. Toxicity rare with 2 gm/hr Comparison studies demon- serum level < 10 mg/dl. Respiratory depression (3 gm/hr strate similar effectiveness and subsequent arrest can occur at levels > 10 to maximum) to other agents in delay 12 mg/dl.78 of delivery. Newborn side effects: Lethargy, hypotonia, respiratory depression, demineralization with prolonged use.

Nifedipine 30 mg oral Nifedipine may offer the Contraindication: Maternal hypotension (Calcium loading dose, best outcomes of the toco- slide 22 Maternal side effects: Flushing, headache, Channel then 10 to 20 lytic agents. May prolong dizziness, nausea, transient hypotension Blocker) mg every four pregnancy for seven days. to six hrs Neonatal mortality not No fetal side effects noted. affected. Decreased incidence of neonatal respiratory distress syndrome, necrotizing enterocolitis, intraventricular hemorrhage and jaundice. slide 23 Terbutaline 0.25 mg Betamimetic drugs may delay Maternal contraindications: Heart disease, (Betamimetic) subcutane- delivery for 48 hours but poorly controlled diabetes, thyrotoxicosis ously every 20 neonatal outcomes are Maternal side effects: minutes for up variable and maternal side - Cardiac arrhythmias, pulmonary edema, to three doses effects common. Terbutaline myocardial ischemia, hypotension, tachycardia should not be used for more than 48 to 72 hours. - Hyperglycemia, hyperinsulinemia, hypokalemia, antidiuresis, altered thyroid function - Physiologic tremor, palpitations, nervousness, nausea/vomiting, fever, hallucinations Fetal and neonatal side effects: - Tachycardia, hypoglycemia, hypocalcemia, hyperbilirubinemia, hypotension, intraventricular hemorrhage

Indomethacin Loading dose: NSAIDs theoretically intervene Contraindications: Maternal renal or hepatic slide 24 (Nonsteroidal 50 mg rectally more proximally in the labor impairment, active peptic ulcer disease. anti-inflamma- or 50 to 100 ‘cascade’ than the other Oligohydramnios tory drug) mg orally agents. Efficacy appears simi- Maternal side effects: Nausea, heartburn Maintenance lar to other agents. Maternal side effect profile is favorable. Fetal side effects: Constriction of the ductus dose: 25 to 50 arteriosus (not recommended after 32 weeks mg orally every Other NSAIDs (sulindac, gestation), pulmonary hypertension, reversible four hours for ketorolac) may be used. decrease in renal function with olioghydramnios, 48 hours intraventricular hemorrhage, hyperbilirubinemia, Total 24-hour necrotizing enterocolitis dose should not be greater May be optimal choice for tocolysis before than 200 mg 32 weeks’ gestation slides 25-27 NEONATAL GROUP B STREPTOCOCCAL (GBS) PROPHYLAXIS Given the current recommendation for universal prenatal screening at 35 to 37 weeks, most patients in preterm labor will not have culture results available. A GBS swab should be obtained for culture when women present with preterm labor or preterm premature rupture of membranes. Rapid tests for GBS colonization in women presenting with threatened PTL, but whose GBS status is unknown, are available;83 however, the 2010 CDC guidelines recommend against using the current nucleic

— Chapter D: Preterm Labor & Premature Rupture of Membranes — 11 acid amplification tests (NATT) in women under 37 weeks’ gestation due to decreased sensitivity compared to culture. Intrapartum antibiotics should be used for prophylaxis until it is determined that the woman is not in true preterm labor, unless a negative GBS culture result becomes available.84 Women who are allergic to penicillin may receive cefazolin unless the allergic response was anaphylaxis, angioedema, respiratory distress, or urticarial. Women with a history of these serious reactions should receive vancomycin unless sensitivity testing has demonstrated that the GBS isolate is susceptible to clindamycin and erythromycin. If sensitive to clindamycin and resistant to erythromycin, then testing for inducible resistance to clindamycin must be performed if clindamycin is to be used rather than vancomycin. CDC algorithms (Figures 4 and 5) for screening and GBS prophylaxis treatment of women with threatened preterm delivery, is presented below:

Figure 4. Algorithm for Screening for Group B Steptococcal (GBS) Colonization and Use of Intrapartum Prophylaxis for Women With Preterm* (PTL)84 slides 28,29

Patient admitted with signs and symptoms of preterm labor

Obtain vaginal-rectal swab for GBS culturea and start GBS prophylaxisb

Patient entering true labor?c

YES NO

Continue GBS prophylaxis Discontinue GBS until deliveryd prophylaxisd

Obtain GBS culture results

Not available prior to labor onset and Positive Negative patient still preterm

GBS prophylaxis at onset No GBS prophylaxis at onset of true labore repeat of true labor vaginal-rectal culture if patient reaches 35 to 37 weeks’ gestation and has not yet deliveredf

* At < 37 weeks and 0 days’ gestation. a If patient has undergone vaginal-rectal GBS culture within the preceding five weeks, the results of that culture should guide management. GBS-colonized women should receive intrapartum antibiotic prophylaxis. No antibiotics are indicated for GBS prophylaxis if a vaginal-rectal screen within five weeks was negative. b See Table 11 for recommended antibiotic regimens. c Patient should be regularly assessed for progression to true labor; if the patient is considered not to be in true labor, discontinue GBS prophylaxis. d If GBS culture results become available prior to delivery and are negative, then discontinue GBS prophylaxis. e Unless subsequent GBS culture prior to delivery is positive. f A negative GBS screen is considered valid for five weeks. If a patient with a history of PTL is re-admitted with signs and symptoms of PTL and had a negative GBS screen > five weeks prior, she should be rescreened and managed according to this algorithm at that time.

12 — — Chapter D: Preterm Labor & Premature Rupture of Membranes Figure 5. Recommended Regimens for Intrapartum Antibiotic Prophylaxis for Prevention of Early-onset Group B Streptococcal (GBS) Disease84

Patient allergic to penicillin?

NO YES

Penicillin G, 5 million units IV initial dose, Patient with a history of any of the following a then 2.5 to 3.0 million units every 4 hrs after receiving penicillin or a cephalosporin?b until delivery • Anaphylaxis or • Angioedema Ampicillin, 2 g IV initial dose, • Respiratory distress then 1 g IV every 4 hrs until delivery • Urticaria

Cefazolin, 2g IV initial dose, Isolate susceptible to clindamycinc then 1 g IV every 8 hrs until delivery and erythromycind?

Vancomycin, 1 g IV every Clindamycin, 900 mg IV 12 hrs until delivery every 8 hrs until delivery

Abbreviation: IV = intravenously * Broader spectrum agents, including an agent active against GBS, might be necessary for treatment of chorioamnionitis. a Doses ranging from 2.5 to 3.0 million units are acceptable for the doses administered every 4 hours following the initial dose. The choice of dose within that range should be guided by which formulations of penicillin G are readily available to reduct the need for pharmacies to specially prepare doses. b Penicillin-allergic patients with a history of anaphylaxis, angioedema, respiratory distress, or urticaria following administration of penicillin, ampicillin, or cefazolin for GBS intrapartum prophylaxis. For penicillin-allergic patients who do not have a history of those reactions, cefazolin is the preferred agent because pharmacologic data suggest it achieves effective intraamniotic concentrations. Vancomycin and clindamycin should be reserved for penicillin-allergic women at high risk for anaphylaxis. c If laboratory facilities are adequate, clindamycin and erythromycin susceptibility testing (Box 3) shold be performed on prenatal GBS isolates from penicillin-allergic women at high risk for anaphylaxis. If no susceptability testing is performed, or the results are not available at the time of labor, vancomycin is the preferred agent for GBS intrapartum prophylaxis for penicillin-allergic women at high risk for anaphylaxis. d Resistance to erythromycin is often but not always associated with clindamycin resistance. If an isolate is resistant to erythromycin, it might have inducible resistance to clindamycin, even if it appears susceptible to clindamycin. If a GBS isolate is susceptible to clindamycin, resistant to erythromycin, and testing for inducible clindamycin resistance has been performed and is negative (no inducible resistance), then clindamycin can be usecd for GBS intrapartum prophylaxis instead of vancomycin.

— Chapter D: Preterm Labor & Premature Rupture of Membranes — 13 PRETERM PREMATURE RUPTURE OF THE FETAL MEMBRANES (PPROM) Twenty-five to 30 percent of preterm deliveries are preceded by PPROM.2 The biochemical events leading to PPROM appear to be different from those leading to PTL. Collagen fibers contribute to the tensile strength of the fetal membranes. Matrix metalloproteinase (a collagenase) activity is increased, possibly the result of infection or other inflammation, and may be the final common pathway leading to membrane rupture. In the context of placental abruption, thrombin may be involved as well.85

The earlier in pregnancy PROM (and PTL in general) occurs, the more likely that it is associated with infection.86 Risk factors for PPROM are similar to those for preterm labor with intact mem- slide 30 branes.50 Delivery is likely within a week of rupture. The earlier in pregnancy the rupture occurs, however, the greater the potential latency period. Clinically evident, intra-amniotic infection will develop in 13 to 60 percent of cases, the likelihood of which is increased by digital vaginal examination.86,87 Principal threats to the fetus are complications of prematurity. Intrauterine complications include umbilical cord compression, abruption of the placenta, infection and pulmonary developmental abnormalities.50 Infection may lead to maternal morbidity and likely plays a role in initiation of labor.

INITIAL EVALUATION OF THE PATIENT WITH SUSPECTED PPROM88,89 • Accurate dating is critical: Review dating criteria as management choices are determined by gestational age. • Sterile speculum examination: If rupture of membranes is suspected, digital examination should be avoided as it shortens the latency period before onset of labor and increases the risk of infection. Diagnosis of rupture of membranes is discussed above. A sample of amniotic fluid may be obtained for fetal lung maturity evaluation if between 32 and 34 weeks (see below). • Ultrasound evaluation: Oligohydramnios supports the diagnosis of membrane rupture. Oligohydramnios will also decrease the accuracy of fetal weight and gestational assessment. Low amniotic volume increases the likelihood of cord compression and other complications. • Assessment of fetal lung maturity: Vaginal amniotic fluid may be tested for phosphatidyl glyc- erol, the presence of which indicates fetal lung maturity90 between 32 and 34 weeks’ gestation, although this is not commonly done. Amniocentesis allows collection of fluid for fetal pulmonary maturity testing as well as for evaluation of infection.91 • Screen for infection: Cervical cultures for sexually transmitted infections or vaginal/rectal culture for group B streptococcus may be obtained. • Fetal monitoring: Electronic fetal heart rate and uterine contraction monitoring during initial assessment may identify cord compression and asymptomatic contractions.

MANAGEMENT OF PPROM As in the case of premature labor with intact membranes, the management of PPROM necessitates a balance between the advantages of delaying delivery and risks of prolonging fetal exposure to a potentially hostile environment. Initial management is predicated on gestational age with the expected benefits of expectant management and administration of corticosteroids increasing for earlier gestational ages. Prolonging pregnancy after 34 weeks may result in poorer outcomes.92

14 — — Chapter D: Preterm Labor & Premature Rupture of Membranes slide 31 • Monitor for clinical infection: Maternal fever, uterine tenderness and fetal tachycardia are indicators of infection. • Antepartum fetal testing: Non-stress testing is useful for detection of fetal heart rate decelerations which may occur due to umbilical cord compression in the setting of oligohydramnios. Biophysical profile testing has been used to predict chorioamnionitis, although daily testing is necessary.93 Oligohydramnios (largest pocket <2 cm) indicates increased risk of infection.93 • Antibiotic therapy: At gestations between 24 and 32 weeks, treatment with antibiotics prolongs pregnancy, decreases fetal morbidity, decreases chorioamnionitis and maternal infection.94 PPROM antibiotic regimens that include ampicillin 1 gram IV every six hours are adequate for GBS prophylaxis per CDC, despite the every six-hours dosing interval rather than the every four hours for routine GBS intrapartum prophylaxis.84 The antibiotics and dosages used in a large National Institute of Child Health and Human Development trial are listed below.95

Table 11. Antibiotic Therapy in PPROM95

Antibiotic Dosage Initial therapy:

Ampicillin 2 grams intravneously every six hours for 48 hours

Erythromycin 250 mg intravenously every six hours for 48 hours

Followed by:

Amoxicillin 250 mg orally every eight hours for five days

Erythromycin base 333 mg orally every eight hours for five days

• Corticosteroids: Antenatal corticosteroid administration in the setting of PPROM reduces the risk of neonatal respiratory distress syndrome (RR 0.56; 95% CI 0.46 to 0.70), intraventricular hemorrhage (RR 0.47; 95% CI 0.31 to 0.70), and necrotizing enterocolitis (RR 0.21; 95% CI 0.05 to 0.82). There is a trend to decreased neonatal death. Incidence of maternal and neonatal infection is not increased.96 The American College of Obstetricians and Gynecologists (ACOG) recommends treatment before 32 weeks. Efficacy of treatment from 32 to 33 weeks is reported as unclear but possibly beneficial in the setting of fetal pulmonary immaturity.97 Corticosteroid dosages are listed above. • Tocolysis: As opposed to antibiotic and corticosteroid treatment, tocolysis in the context of PPROM lacks evidence of benefit. Association of infection with onset of labor would be expected to be stronger in PPROM as opposed to PTL with intact membranes indicating circumspection in choosing tocolysis. ACOG has no recommendation regarding tocolysis in PPROM.86

GESTATIONAL AGE AND MANAGEMENT OF PPROM slide 32 Greater than or equal to 34 weeks, electively induce labor: Incidence of RDS as well as composite morbidity in neonates delivered in the 34th week is no different from those in the 35th and 36th weeks.92 Interventions such as corticosteroids and antibiotics are no longer indicated. At 34 weeks, elective induction of labor with PPROM reduces the incidence of chorioamnionitis and neonatal sepsis.92

— Chapter D: Preterm Labor & Premature Rupture of Membranes — 15 Thirty-two to 33 weeks, induce if fetal lungs mature based on amniocentesis or vaginal pool sample. As with induction versus observation after 34 weeks, elective induction improves outcomes in pregnancies with evidence of fetal lung maturity. For those pregnancies without fetal lung maturity, management is less clear. Corticosteroid and antibiotic therapy are a consideration.80,86,98

Twenty-four to 32 weeks, administer antibiotics and corticosteroids, monitor for infection and other intrauterine fetal complications. If there is no evidence of fetal compromise and labor does not begin spontaneously, these pregnancies are managed expectantly until they reach 34 weeks.50,86,91

DELIVERY OF THE PRETERM INFANT Premature delivery at a facility with a high-volume level III Neonatal Intensive Care Unit (NICU) results in slide 33 better neonatal outcomes.99 If delivery is not imminent and level III services are unavailable, then maternal transfer is indicated. Using a proactive approach wherein very preterm infants (22 to 26 weeks’ gestation) were delivered at a level III facility and antenatal steroids were delivered, one-year survival rates were 70 percent, ranging from 9.8 percent at 22 weeks to 85 percent at 26 weeks.100 Fetuses at 22 to 25 weeks are considered at the cusp of viability and decisions for intervention with tocolysis, cesarean delivery for nonreassuring fetal heart tones, and neonatal intensive unit care requires careful consultation with parents and consideration of the specific risks and benefits. The National Institute of Child Health and Human Development (NICHD) has developed a web-based tool for describing outcomes of these neonates based on gestational age, weight, sex, and administration of antenatal corticosteroids. (http://www.nichd.nih.gov/about/org/cdbpm/pp/prog_epbo/epbo_case.cfm).

The preterm fetus is more susceptible to injury from acidosis and anoxia and therefore should be monitored continuously.101 Neurologic immaturity of the fetus and effects of medications such as betamimetics complicate fetal heart rate monitoring. Malpresentations are more common at earlier gestations and should be anticipated.102

There is some retrospective evidence that elective cesarean delivery of extremely premature (22 to 31 weeks’ gestation)103 or very low birth weight (< 750 grams) infants104 may improve some neonatal outcomes. The beneficial effect of elective cesarean delivery of these fetuses is not apparent, however, when applied to all deliveries at less than 37 weeks’ gestation, while increasing maternal morbidity.105 The lack of specificity in the diagnosis of true preterm labor results in the theoretical risk of surgical delivery of a patient not truly in preterm labor, an eventuality suggested in one of the trials.105 For these reasons, cesarean delivery for the vertex preterm fetuses should be done for standard obstetric indications rather than for prematurity.106

There is no evidence that prophylactic episiotomy or forceps delivery improves neonatal outcome in preterm delivery.106,107 Use of vacuum extraction is generally considered inappropriate before 34 weeks’ gestation, due to the risk of intraventricular hemorrhage.108 Umbilical cord blood acid-base studies should be considered following delivery given higher rates of cerebral palsy in preterm infants. The third stage of labor may be prolonged. Retained placenta is more common than with term pregnancies109 and is best managed with uterine stimulants.

16 — — Chapter D: Preterm Labor & Premature Rupture of Membranes slide 34 PREMATURE RUPTURE OF MEMBRANES (PROM) AT TERM Rupture of the membranes prior to the onset of labor occurs in 10 percent of pregnancies. Ninety percent of PROM occurs at greater than 37 weeks’ gestation.110 Diagnosis of ruptured membranes is discussed above. PROM at term confronts the clinician with several treatment decisions.

Positive amniotic fluid cultures for almost one-third of women presenting with PROM at term have been demonstrated, although only a small proportion will go on to develop clinical chorioamnionitis or endometritis.111 Since maternal chlamydial and gonorrheal infections increase the risk for PROM, consider cervical cultures.112 For women who are colonized, antimicrobial chemoprophylaxis for GBS is discussed above. If GBS status is unknown at time of presentation, intrapartum chemoprophylaxis should be administered to women with duration of membrane rupture > 18 hours, or temperature > 100.4ºF (> 38ºC).84 As in PPROM, digital cervical examinations are associated with increased incidence of chorioamnionitis113 and neonatal infection.114

PLANNED DELIVERY VS. EXPECTANT MANAGEMENT IN PATIENTS NOT IN LABOR Labor induction with oxytocin is recommended when term PROM occurs and labor does not follow.115 Despite this recommendation, some women may prefer expectant management. The Cochrane review on term PROM concludes that since the difference in outcomes based on management plan is small, women should receive information to make an informed choice.116 Elective induction of labor does not reduce the incidence of neonatal infection overall, but does decrease admissions to newborn intensive care (RR 0.72; CI 0.56 to 0.97). Mothers are less likely to develop chorioamnionitis (RR 0.74; CI 0.56 to 0.97) or endometritis (RR 0.30; CI 0.12 to 0.74).116 Actively managed GBS-colonized mothers, however, deliver neonates with significantly lower rates of infection (2.5 percent) than those who are expectantly managed (eight percent).117 Elective induction does not increase the rate of cesarean deliveries in the setting of term PROM.118 Oral and vaginal misoprostol as well as PGE2 have been used for elective induction of labor in the setting of term PROM but offer no advantage over oxytocin.119

CONCLUSION It is possible to identify some patients at high risk for PTD, and a subset of these may benefit from slides 35,36 preventive interventions such as antenatal progesterone. In the triage of patients presenting with preterm contractions, it is possible to stratify their risk of subsequent preterm delivery. The major role of tocolysis is delay of delivery for the 48 hours necessary for the full therapeutic effect of antenatal steroids. Management of PPROM presents its own set of challenges and is primarily based on gestational age. Antenatal steroids and antibiotics are useful in some cases. Although term PROM is often managed expectantly, there is little research to support that approach and some to support immediate induction of labor or after a short interval of expectant management. Preterm labor remains an area of intense research activity and therapeutic evolution. Addressing the role of infection in PTL is a particular area of interest.

— Chapter D: Preterm Labor & Premature Rupture of Membranes — 17 SUMMARY Category A Antenatal progesterone supplementation decreases the incidence of preterm delivery in high-risk patients.32 Administration of corticosteroids in women with preterm labor between 26 and 34 weeks’ gestation reduces the incidence of neonatal death, respiratory distress syndrome, and intraventricular hemorrhage.63 In symptomatic patients, calcium channel blockers reduce the risk of delivery within seven days and before 34 weeks’ gestation. Calcium channel blockers are better tolerated than betamimetics.69 In symptomatic patients, betamimetics decrease the risk of delivery within 48 hours. They are associated with significant adverse effects, and should not be used for more than 48 to 72 hours.71

Category C If delivery is not imminent, maternal transfer to a facility with a level III neonatal intensive care unit is indicated.99,100

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20 — — Chapter D: Preterm Labor & Premature Rupture of Membranes 63. Roberts D, Dalziel SR. Antenatal corticosteroids 80. American College of Obstetricians and Gynecologists for accelerating fetal lung maturation for women at Committee on Obstetric Practice; Society for Maternal- risk of preterm birth. Cochrane Database Syst Rev. Fetal Medicine. Magnesium sulfate before anticipated 2006(3):CD004454. preterm birth for neuroprotection. Obstet Gynecol. 64. ACOG Committee Opinion No. 402. Antenatal 2010:115(3):669-671. corticosteroid therapy for fetal maturation. Obstet 81. Doyle LW, Crowther CA, Middleton P, et al. Antenatal Gynecol. 2008;111(3):805-807. magnesium sulfate and neurologic outcome in 65. National Institutes of Health Consensus Development preterm infants, a systematic review. Obstet Gynecol. Panel. Antenatal corticosteroids revisited: repeat 2009;113(6):1327-1333. courses - National Institutes of Health Consensus 82. Rouse DJ, Hirtz DG, Thom E, et al. A randomized, Development Conference Statement, August 17-18, controlled trial of magnesium sulfate for the prevention 2000. Obstet Gynecol. 2001;98(1):144-150. of cerebral palsy. N Engl J Med. 2008;(9)359:895-905. 66. Garite TJ, Kurtzman J, Maurel K, et al. Impact of a 83. Honest H, Sharma S, Khan KS. Rapid tests for group ‘rescue course’ of antenatal corticosteroids: a B Streptococcus colonization in laboring women: a multicenter randomized placebo-controlled trial. systematic review. Pediatrics. 2006;117(4):1055-1066. Am J Obstet Gynecol. 2009;200(3):248.e1-9. 84. Centers for Disease Control and Prevention. 67. Guinn DA, Atkinson MW, Sullivan L, et al. Single vs Prevention of perinatal group B Streptococcal disease weekly courses of antennal corticosteroids for women revised guidelines from CDC, 2010. MMWR Recomm at risk of preterm delivery: a randomized controlled Rep. 2010;59(RR-10):1-36. trial. JAMA. 2001;286(13):1581-1587. 85. Thomson A, Norman J. Biology of preterm labour. 68. Wapner RJ, Sorokin Y, Mele L, et al. Long-term out- Norman J, Greer I (eds). Preterm Labour, managing comes after repeat doses of antenatal corticosteroids. risk in clinical practice. Cambridge, UK: Cambridge N Engl J Med. 2007;357(12):1190-1198. University Press; 2005. 26-75. 69. King JF, Flenady V, Papatsonis D, et al. Calcium 86. ACOG Committee on Practice Bulletins-Obstetrics. channel blockers for inhibiting preterm labour. ACOG practice bulletin No. 80: premature rupture Cochrane Database Syst Rev. 2003(1): CD002255. of membranes. Clinical management guidelines 70. Naik Gaunekar N, Crowther CA. Maintenance therapy for obstetricians-gynecologists. Obstet Gynecol. with calcium channel blockers for preventing preterm 2007;109(4):1007-1019. birth after threatened preterm labour. Cochrane 87. Alexander JM, Mercer BM, Miodovnik M, et al. The Database Syst Rev. 2004(3): CD004071. impact of digital cervical examination on expectantly 71. Anotayanonth S, Subhedar NV, Neilson JP, et al. managed preterm rupture of membranes. Am J Obstet 2000;183:1003-1007. Betamimetics for inhibiting preterm labour. Cochrane Gynecol. Database Syst Rev. 2004(4):CD004352. 88. Combs CA, McCune M, Clark R, et al. Aggressive 72. King JF, Flenady V, Cole S, et al. Cyclo-oxygenase tocolysis does not prolong pregnancy or reduce neonatal morbidity after preterm premature (COX) inhibitors for treating preterm labour. Cochrane rupture of the membranes. Database Syst Rev. 2005(2):CD001992. Am J Obstet Gynecol. 2004;190(6):1723-1731. 73. Norton ME, Merrill J, Cooper B, et al. Neonatal complications after the administration of indomethacin for 89. Mercer BM, Crocker LG, Boe NM, et al. Induction versus expectant management in premature rupture preterm labor. N Engl J Med. 1993;329(22):1602-1607. of the membranes with mature amniotic fluid at 32 to 74. Loe SM, Sanchez-Ramos L, Kaunitz AM. Assessing 36 weeks: a randomized trial. Am J Obstet Gynecol. the neonatal safety of indomethacin tocolysis. Obstet 1993;169(4):775-782. Gynecol. 2005:106(1):173-179. 90. Lewis DF, Futayyeh S, Towers CV, et al. Preterm 75. Haas DM, Imperiale TF, Kirkpatrick PR, et al. Tocolytic delivery from 34 to 37 weeks of gestation: is therapy, a meta-analysis and decision analysis. Obstet respiratory distress syndrome a problem? Am J Gynecol. 2009;113(3):585-594. Obstet Gynecol. 1996;174(2):525-528. 76. Simhan H, Caritis SN. Prevention of preterm delivery. 91. Simhan HN, Canavan TP. Preterm premature rupture N Engl J Med. 2007;357(5):477-487. of membranes: diagnosis, evaluation and manage- 77. Fox NS, Gelber SE, Kalish R, et al. Contemporary ment strategies. BJOG. 2005;112(Suppl 1):32-37. practice patterns and beliefs regarding tocolysis 92. Naef RW, Allbert JR, Ross EL, et al. Premature rupture among US maternal-fetal medicine specialists. of membranes at 34-37 weeks’ gestation: aggres- Obstet Gynecol. 2008;112(1):42-47. sive versus conservative management. Am J Obstet 78. Mercer BM, Merlino AA. Magnesium sulfate for Gynecol. 1998;178(1 Pt 1):126-130. preterm labor and preterm birth. Obstet Gynecol. 93. Hanley ML, Vintzileos AM. Biophysical testing in 2009;114(3):650-668. premature rupture of the membranes. Sem Perinatol. 79. Crowther CA, Hiller JE, Doyle LW. Magnesium 1996;20(5):418-425. sulphate for preventing preterm birth in threatened preterm labour. Cochrane Database Syst Rev. 2002(4):CD001060.

— Chapter D: Preterm Labor & Premature Rupture of Membranes — 21 94. Kenyon S, Boulvain M, Neilson J. Antibiotics for pre- 108. American College of Obstetricians and Gynecologists. term rupture of the membranes: a systematic review. Operative vaginal delivery. Clinical management Obstet Gynecol. 2004;104(5 Pt 1):1051-1057. guidelines for obstetrician-gynecologists. 95. Mercer BM, Miodovnik M, Thurnau GR, et al. Antibiotic Int J Gynaecol Obstet. 2001;74(1): 69-76. therapy for reduction of infant morbidity after 109. Romero R, Hsu YC, Athanassiadis AP, et al. preterm rupture of the membranes: a randomized Preterm delivery: a risk factor for retained placenta. trial. National Institute of Child Health and Human Am J Obstet Gynecol. 1990;163(3):823-825. Development Maternal-Fetal Medicine Units Network. 110. Naylor CS, Gregory K, Hobel C. Premature rupture JAMA. 1997;278(12):989-995. of the membranes: an evidence-based approach to 96. Harding JE, Pang J-M, Knight DM, et al. Do clinical care. Am J Perinatol. 2001;18:397-413. antenatal corticosteroids help in the setting of 111. Romero R, Mazor M, Morrotti R, et al. Infection and preterm rupture of membranes? Am J Obstet labor. VII. Microbial invasion of the amniotic cavity in Gynecol. 2001;184(2):131-139. spontaneous rupture of membranes at term. 97. American College of Obstetricians and Gynecologists Am J Obstet Gynecol. 1992;166(1 Pt 1):129-133. Committee on Obstetric Practice. ACOG Committee 112. Ekwo ER, Gosselingk CA, Woolson R, et al. Risks Opinion No. 402. Antenatal corticosteroid therapy for for premature rupture of amniotic membranes. fetal maturation. 2008;111:805-807. Obstet Gynecol. Int J Epidemiol. 1993;22(3):495-503. 98. Medina TM, Hill DA. Preterm Premature Rupture of 113. Seaward PG, Hannah ME, Myhr TL, et al. International Membranes: Diagnosis and Management. Am Fam multicentre term PROM study: evaluation of predictors Physician. 2006;73(4):659-664. of neonatal infection in infants born to patients with 99. Warner B, Musial J, Chenier T, et al. The effect of birth premature rupture of membranes at term. Preterm hospital type on the outcome of very low birth weight rupture of the membranes. Am J Obstet Gynecol. infants. Pediatrics. 2004;113(1 Pt 1):35-41. 1998;179(3 Pt 1):635-639. 100. EXPRESS Group, Fellman V, Hellstrom-Westas L, 114. Seaward PG, Hannah ME, Myhr T, et al. International Norman M, et al. One-year survival of extremely multicentre term prelabor rupture of membranes preterm infants after active perinatal care in Sweden. study: evaluation of predictors of clinical chorioamnio- JAMA. 2009;301(21):2225-2233. nitis and postpartum fever in patients with prelabor 101. Westgren LM, Malcus P, Svenningsen N. Intrauterine rupture of membranes at term. Am J Obstet Gynecol. asphyxia and long-term outcome in preterm fetuses. 1997;177(5):1024-1029. Obstet Gynecol. 1986;67(4):512-516. 115. American College of Obstetricians and Gynecologists. 102. Bottoms S. Delivery of the premature infant. Premature Rupture of Membranes. ACOG Practice Bulletin No. 80. 2007;109:1007-1019. Clin Obstet Gynecol. 1995;38(4):780-789. Obstet Gynecol. 103. Mallow MH. Impact of cesarean section on 116. Dare MR, Middleton P, Crowther CA, et al. Planned neonatal mortality rates among very preterm early birth versus expectant management (waiting) for prelabour rupture of membranes at term infants in the United States, 2000-2003. Pediatrics. 2008;122(2):285-292. (37 weeks or more). Cochrane Database Syst Rev. 2006(1):CD005302. 104. Deulofeut R, Sola A, Lee B, et al. The impact of vaginal delivery in premature infants weighing less than 117. Hannah ME, Ohlsson A, Wang EEL, et al. Maternal colonization with group B Streptococcus and prelabor 1,251 grams. Obstet Gynecol. 2005;105(3):525-531. rupture of membranes at term: the role of induction of 105. Riskin A, Riskin-Mashiah S, Lusky A, et al. The labor. TermPROM Study Group. Am J Obstet Gynecol. relationship between delivery mode and mortality 1997;177(4):780-785. in very low birthweight singleton vertex-presenting 118. Peleg D, Hannah ME, Hodnett ED, et al. Predictors infants. BJOG. 2004;111(12):1365-1371. of cesarean delivery after prelabor rupture of mem- 106. Goldenberg RL. The management of preterm labor. branes at term. Obstet Gynecol. 1999;93(6):1031-1035. Obstet Gynecol. 2002;100(5 Pt 1):1020-1037. 119. Mozurkewich EL, Wolf FM. Premature rupture of mem- 107. Platek D, Chazotte C, Schulman M. Episiotomy does branes at term: a meta-analysis of three management not protect against intraventricular hemorrhage in the schemes. Obstet Gynecol. 1997;89(6):1035-1043. very-low-birth-weight neonate. Am J Obstet Gynecol. 1993;168:371-376.

22 — — Chapter D: Preterm Labor & Premature Rupture of Membranes Chapter E Intrapartum Fetal Surveillance slide 1 R. Eugene Bailey, MD Published June 2011

OBJECTIVES slide 2 After completing this chapter, participants will be able to: 1. List the indications for use of continuous electronic fetal monitoring (CEFM) and structured intermittent auscultation (SIA). 2. Describe guidelines for CEFM terminology including definitions and interpretation of Fetal Heart Rate tracings (NICHD 1997, revised 2008). 3. Discuss the mnemonic DR C BRAVADO and recent ACOG guidelines to develop an overall assessment and general management plan. 4. Discuss future trends in fetal monitoring.

INTRODUCTION slide 3 History of CEFM CEFM was developed and introduced in the 1960s and rapidly became part of routine obstetrical practice. From 1980 to 2002, CEFM use increased dramatically from 40 percent to over 85 percent of women in labor.1 CEFM has resulted in an increased use of cesarean delivery, however the incidence of perinatal mortality and cerebral palsy has not fallen, and a decrease in neonatal seizures is the only demonstrable benefit.2 CEFM as a screening test for fetal hypoxemia or acidemia remains limited by low specificity, as a very high proportion of abnormal fetal monitoring tracings occur in fetuses with normal pH and oxygenation.

Utilization of CEFM is limited by a lack of interobserver and intraobserver reliability in interpretation.3 The following concerns were listed in the Confidential Enquiry into Stillbirths and Deaths in Infancy (CESDI) Fourth Annual Report at the Maternal and Child Health Research Consortium:4

1. Failure to perform CEFM when there is a valid indication. 2. Failure to ensure a good quality tracing when it is indicated. 3. Failure to recognize a fetal heart tracing as abnormal or normal. 4. The use of uterine stimulation or regional anesthesia in the presence of unresolved abnormality of the fetal heart rate. 5. Failure to act appropriately when the fetal heart rate is abnormal. 6. Delay in expediting delivery once fetal compromise is identified or suspected.

— Chapter E: Intrapartum Fetal Surveillance — 1 INDICATIONS FOR CEFM Indications for CEFM include maternal medical problems, pregnancy-related risk factors and labor complications:7

Maternal Indications (antenatal) slide 4 1. Hypertension (pre-eclampsia, eclampsia) 2. Diabetes 3. Cardiac disease 4. Hemoglobinopathy 5. Severe anemia 6. Hyperthyroidism 7 Collagen vascular disease 8. Renal disease

Maternal Indications (intrapartum) 1. Vaginal bleeding in labor 2. Intrauterine infection

Fetal Indications (intrapartum) slide 5 1. Meconium-stained amniotic fluid 2. Suspicious fetal heart rate on auscultation 3. Abnormal FHR on the admission tracing (20 minute strip) 4. Post-term pregnancy

Fetal Indications (antepartum) 1. Multiple pregnancies 2. Intra-uterine growth restriction 3. Preterm labor (< 37 weeks) 4. Breech presentation 5. Rh isoimmunization 6. Oligohydramnios 7. Abnormal umbilical artery Doppler velocimetry

Labor Indications slide 6 1. Induced or augmented labor 2. Prolonged labor 3. Regional analgesia, particularly after initial bolus and after top-ups 4. Thick meconium 5. Abnormal fetal heart rate or concerning decelerations in structured intermittent auscultation (SIA) 6. Vaginal bleeding in labor 7. Abnormal uterine activity 8. Previous cesarean section

2 — — Chapter E: Intrapartum Fetal Surveillance slide 7 FACTORS TO CONSIDER IN CHOOSING FETAL SURVEILLANCE TECHNIQUE The opportunity may or may not exist to perform SIA in any given delivery suite, leaving continuous electronic fetal monitoring (CEFM) as the only option. The American College of Obstetricians and Gynecologists (ACOG) presents intermittent auscultation as an acceptable choice in low risk pregnancies.6 Selection of monitoring technique depends on risk factors outlined above and the following:

Risk of Mother and Fetus The decision to choose SIA or CEFM begins with assessing the risk of mother and fetus, in order to identify the fetus at risk for uteroplacental insufficiency, intrapartum demise or neonatal neurological damage. After categorizing the risk factors, a decision can be made on how best to proceed to achieve optimal fetal surveillance.

Staff Availability and Level of Comfort One of the critical steps in choosing a method of fetal surveillance is a consideration of the personnel available on the labor floor, especially in the case of SIA. The comfort level of the nurses who may not be accustomed to SIA should be assessed. An in-service may be used to familiarize nurses with auscultative monitoring technique or enhance their skill and comfort level.

Informed Consent of the Patient A discussion of how the fetus will be monitored during labor should occur before the onset of labor, so that options can be explored and any questions answered. Advantages and disadvantages of both CEFM and SIA can be reviewed at this time, and patient preferences can be more effectively determined.

Admission Fetal Monitor Strip Most, if not all women, in the United States will be placed on the electronic fetal monitor for 20 minutes when they present to the labor floor. The method of fetal monitoring will then be determined based on the interpretation of this 20-minute strip. In some cases, mothers will be left on the fetal monitor for another 20 minutes if the strip is deemed problematic. This routine use of admission monitoring is discouraged based on a recent systematic review that has shown no significant difference compared to patients starting on SIA without an admission strip5 This admission monitor strip should not predetermine the type of monitoring, CEFM or SIA, and its routine use should be recon- sidered by obstetrical providers.

EFFECT OF FETAL SURVEILLANCE ON PATIENT, SUPPORT PERSONNEL AND STAFF The effect fetal surveillance has on all individuals present during labor and delivery must be considered. Use of CEFM decreases mobility, reduces contact between the woman and her partner, and eliminates the need for close contact by the labor nurse. CEFM should not be used as a substitute for continuous care during labor.

— Chapter E: Intrapartum Fetal Surveillance — 3 Outcomes with CEFM slide 8 The only clinically significant benefit demonstrated with routine CEFM is the reduction of neonatal seizures in the immediate newborn period, although at the end of one year these infants did not suffer any permanent sequelae.2 No significant differences have been demonstrated in one-minute Apgar scores below seven, rate of admissions to neonatal intensive care units, and perinatal deaths. Even when combined with fetal scalp pH sampling, CEFM has not been shown to reduce perinatal mortality or reduce the incidence of cerebral palsy. The use of CEFM does increase the rate of cesarean and operative vaginal deliveries.2

There has been and still is an unrealized expectation that an abnormal non-reassuring FHR tracing will predict cerebral palsy. The incidence of cerebral palsy has been stable since the introduction of EFM, as expected since cerebral palsy is attributed to events prior to labor in approximately 70 percent of the cases and only four percent of cases caused by hypoxic ischemic encephalopathy (HIE) can be directly linked to intrapartum events.6 In newborns with estimated fetal weight > 2500 g, it has been estimated that the positive predictive value of an abnormal FHR tracing in predicting cerebral palsy is 0.14 percent.6

Since the outcomes from CEFM have shown only minimal short-term benefit and potential for harm, any potential benefit of CEFM should be evaluated in light of risk status of the patient. A joint decision between the pregnant woman and her clinician should then be made regarding use of CEFM vs. SIA during labor. To date, no studies have been done to assess the optimal frequency for SIA in the absence of risk factors. SIA should be performed based on specific guidelines:

Table 1. Structured Intermittent Auscultation slide 9 Frequency of Auscultation6

1. Every 15 minutes in active phase of first stage of labor 2. Every five minutes in second stage of labor with pushing

When to Auscultate7

Assess FHR before: Assess FHR after: 1. Initiation of labor augmentation 1. Admission of patient 2. Ambulation of patient 2. Artificial or spontaneous rupture of membrane 3. Administration of medications 3. Vaginal exam 4. Administration or initiation of analgesia/anesthesia 4. Abnormal uterine activity 5. Evaluation of analgesia/anesthesia

Procedure for Auscultation7

Procedure for Auscultation7 1. Palpate the abdomen to deteremine the position of the fetus (Leopold’s maneuver). 2. Place the Doppler over the area of maximum intensity of fetal heart tones. 3. Differentiate maternal pulse from fetal pulse. 4. Palpate for uterine contraction during period of FHR auscultation to determine relationship. 5. Count FHR between contractions for at least 60 seconds to determine the average baseline rate. 6. Count FHR after uterine contraction for 60 seconds at six second intervals to indentify fetal response to active labor. (This may be subject to local protocols.)

4 — — Chapter E: Intrapartum Fetal Surveillance Successful implementation of SIA can be achieved keeping in mind the following guidelines:8 1. The presence of nurses and practitioners experienced in the technique of auscultation, the palpation of contractions, and the auditory recognition of FHR changes are necessary. 2. Institutional policy should be developed addressing the technique and frequency of assessment. 3. Clinical interventions should follow when concerning findings are present. 4. Nurse-to-fetus ratio needs to be one-to-one since fetal heart tones are required to be heard every 15 minutes. Controlled trials comparing IA and EFM were performed with skilled OB nurses in constant attendance with each patient during labor. slide 10 INTERPRETATION OF FETAL HEART RATE ABNORMALITIES CEFM has been under close scrutiny due to the lack of consistent interpretation of fetal heart rate tracings, even by perinatologists.3 The National Institute of Child Health and Human Development (NICHD) in 1997 developed guidelines to “…allow identification of fetal asphyxia so that timely intervention can avoid brain damage or death.” NICHD added “a major impediment is lack of agreement in definitions and nomenclature of FHR patterns.”9 In 2008 NICHD revised their definitions, interpretation and research guidelines.10 NICHD reviewed the fetal monitoring approach used in the United Kingdom and Sweden, as well as the work of Parer.11 ACOG incorporated these guidelines into a 2009 practice bulletin on electronic fetal monitoring definitions and the three-tiered fetal heart rate interpretation system (Practice Bulletin No 106).6 In 2010 ACOG released a second practice bulletin on management of intrapartum fetal heart tracings based on the three-tier category system and management of uterine tachysystole (Practice Bulletin No 116).7 ACOG describes FHR tracings as visual patterns that should be adaptable to computerized interpretation and that definitions should be applied to intrapartum tracings but also can be used for antepartum FHR tracings. Categorization of FHR tracings are for intrapartum only. slide 11 When performing electronic fetal monitoring, it is recommended that the fetal strips be reviewed periodically. For uncomplicated patients, fetal monitor strips should be reviewed every 30 minutes during stage one and every 15 minutes during Stage two. If the pregnancy is complicated (e.g., IUGR, pre-eclampsia, etc), then review of monitoring is more frequent: every 15 minutes during stage one and every five minutes during stage two.6 slide 12 DR C BRAVADO DR C BRAVADO Determine Risk The mnemonic DR C BRAVADO is a systematic approach to the interpreta- Contractions tion of FHR tracings for both CEFM and SIA. When using this mnemonic for Baseline RAte either technique, the record of both FHR and uterine contractions should be Variability adequate for visual interpretation for CEFM or a composite of intermittent Accelerations auscultation between contractions (baseline) and during six-second intervals Decelerations for 60 seconds during and after palpated contractions for SIA.12 Overall Assessment slide 13 Determine Risk Before any FHR tracing can be interpreted, the background history of the patient is evaluated so that risk can be determined.12 Fetal reserve is assessed in view of the clinical situation. Is this a term, low-risk baby, or are there risk factors present such as growth restriction, pre-eclampsia,

— Chapter E: Intrapartum Fetal Surveillance — 5 chorioamnionitis or meconium? Is labor progressing well, or is there associated dystocia? Is an assisted vaginal delivery likely? It is also important to consider if multiple risk factors are present, rather than focusing on one isolated risk factor. For example, smoking as an isolated risk factor may not change the approach taken clinically, when the fetus is term and normal size, whereas smoking in a teenager with iron deficiency anemia and an eating disorder may signal a high-risk situation. slide 14 Contractions The method of monitoring can be performed using a pressure transducer (either external or via an intrauterine pressure catheter) or palpation in order to determine the amplitude and frequency of contraction. Strength of a contraction cannot be determined with the external pressure transducer and requires placement of an IUPC or palpation. Uterine contractions are quantified as the number present over a 10 minute period, averaged over 30 minutes.

Contractions are classified as normal (< five contractions in a 10 minute period) or tachysystole (> five contractions in a 10 minute period).10 Tachysystole is qualified as to the presence or absence of decelerations and the term applies to both spontaneous and stimulated labor. Hyperstimulation and hypercontractibilty are not defined and these terms should be abandoned.10 slides 15-17 Baseline RAte Baseline rate is calculated by averaging the rate rounded to five bpm intervals over a 10 minute segment. Segments should be excluded that have marked variability (> 25 bpm) are greater than or equal to 25 bpm above or below the baseline or containing accelerations or decelerations. There must be at least a two-minute identifiable segment with in any 10 minute window. The normal range is 110 to 160 bpm.10 When performing SIA, average baseline rate should be determined between contractions. A change in baseline rate can be due to prematurity, change in fetal status, maternal fever, position, or medication. slide 18 Bradycardia Bradycardia is defined as a baseline < 110 bpm.10 Mild bradycardia (100 to 109 bpm) is associated with post-dates infants and occipito-posterior position.10 Rates less than 100 bpm may be seen in fetuses with congenital heart disease or myocardial conduction defects.12 slide 19 Tachycardia Tachycardia is defined as a baseline rate > 160 bpm.10 Fetal movement, maternal anxiety or fever, maternal dehydration or ketosis and beta-adrenergic agents all may cause fetal tachycardia unas- sociated with hypoxia.12 Fetal immaturity, thyrotoxicosis and anemia may also cause mild tachycardia.12 Persistent tachycardia greater than 180 bpm, especially if mater fever is present, suggests chorioamnionitis.12 A fetal heart rate greater than 200 bpm is frequently due to fetal arrhythmia or other congenital anomaly.12 slide 20 Variability The fetal heart rate normally exhibits fluctuations in baseline heart rate activity that is irregular in amplitude and frequency. The variability is linked to the central nervous system (CNS) reflecting cerebral activity. It is therefore a vital clue in determining the overall fetal condition.6 Detection is most accurate with a scalp electrode, although newer external transducers have improved ability to detect variability. Absent baseline variability is the finding that is most strongly associated with fetal

6 — — Chapter E: Intrapartum Fetal Surveillance asphyxia,6 but has very poor specificity with estimated positive predictive value ranged from 2.6 to 18.1 percent.13 The presence of moderate variability as defined is highly predictive of a nonacidotic fetus.7 For structured intermittent auscultation, it is difficult to interpret variability using the same nomenclature for CEFM.

NICHD guidelines state that variability is no longer to be described as short-term (beat-to-beat) or long-term. Definitions to characterize variability are specifically classified as follows: absent, minimal, moderate, or marked.10 slides 21-24 Absent variability amplitude range is undetectable. Minimal variability amplitude range detectable but < five bpm Moderate variability amplitude range is six to 25 bpm Marked variability amplitude range is > 25 bpm slides 25 The amount of variability is affected by the fetal state and by multiple causes other than uteroplacental insufficiency resulting in acidosis. Normal babies may have decreased variability with no known cause. Sleep cycles of 20 to 40 minutes or longer may cause a normal decrease in variability. Medications including analgesics, anesthetics, barbiturates, tranquilizers, atropine, and magnesium sulfate may also induce quiet periods in the FHR tracing without fetal compromise. Steroid administration to induce fetal lung maturation also reduces variability. A fetus with anencephaly will have a relatively flat baseline.12 slides 26-27 Accelerations Accelerations are visually apparent abrupt increases in FHR tracing above the most recent baseline with an onset to peak in < 30 seconds. The peak of the acceleration is > 15 bpm (> 10 bpm if < 32 weeks gestation) and lasts for > 15 seconds (> 10 seconds if < 32 weeks gestation).9 The return to baseline is within two minutes. If the acceleration lasts > two minutes but < 10 minutes, then it is defined as a prolonged acceleration. The absence of accelerations does not necessarily indicate fetal compromise, but does warrant the need for further evaluation. When used in antenatal testing, a contraction stress test (CST) or biophysical profile (BPP) would be required to clarify fetal status in the presence of a nonreactive stress test (NST). The presence of spontaneous or stimulated accelerations is highly predictive of a nonacidotic fetus.7

When accelerations are seen in association with contractions and variable decelerations, they may indicate partial cord compression. Their disappearance may signal fetal hypoxia, especially with other indicators of compromise, such as worsening variable decelerations, decreased baseline variability, baseline tachycardia or bradycardia.12 slide 28 Decelerations Decelerations are defined in terms of their relationship to uterine contractions. If they occur with > 50 percent of contractions in any 20 minute window they are considered to be recurrent decelerations. If they occur < 50 percent of contractions in any 20 minute window they are termed intermittent decelerations. Decelerations are classified as early, variable or late.10 slides 29-30 Early Decelerations Early decelerations are visually apparent, gradual decrease in FHR with return to baseline in association with a uterine contraction. The onset to nadir is > 30 seconds and the nadir occurs at the

— Chapter E: Intrapartum Fetal Surveillance — 7 same time as the peak of the contraction.10 They are nearly always benign if no other abnormali- slides 31-32 ties of the FHR tracing are noted and represent transient local changes in blood flow as a result of stimulus of the vagal nerve centers due to head compression.

Variable Decelerations Variable decelerations are visually apparent abrupt decrease in FHR below the baseline with onset to nadir < 30 seconds. The decrease in FHR is > 15 bpm with duration of > 15 seconds but < two minutes and may not be associated with contractions.10 Variable decelerations are most commonly the result of cord compression resulting in a rise in peripheral resistance and change in oxygenation. This causes sudden fetal hypertension, increased parasympathetic outflow and slows the fetal pacemaker. Interpretation is complicated, however, because decreased arterial oxygen concentration, secondary to uteroplacental insufficiency from other causes, can also result in variable decelerations. Characteristics of benign variable decelerations (good fetal reserve) include rapid descent and recovery, good baseline variability and accelerations at the onset and at the end of the contraction. Concerning signs include late onset, slow recovery, decreased variability, baseline tachycardia, loss of accelerations (or “shoulders”) if previously present, and increased depth of the variable decelerations.12

Late Decelerations slides 33-34 Late decelerations are visually apparent gradual decreases in FHR with return to baseline where the onset to nadir > 30 seconds. The onset, nadir and recovery of the deceleration occur after the beginning, peak and ending of the contraction.10 If uncorrected, repetitive late decelerations are frequently associated with uteroplacental insufficiency and fetal hypoxemia leading to academia and myocardial depression. When combined with decreased variability or other FHR abnormalities, there is an increased likelihood of significant fetal compromise and immediate evaluation and intervention are indicated. Subtle, shallow late decelerations are easily missed but clinically significant. They can be detected by holding a straight edge along the baseline.

Prolonged Decelerations slides 35-36 Prolonged decelerations are visually apparent decreases in FHR baseline > 15 bpm, lasting > two minutes, but < 10 minutes.10

A sudden deterioration in the fetal heart rate pattern can be seen after vaginal examination, amniot- slide 37 omy, uterine tachysystole secondary to oxytocin or a cervical ripening agent, maternal hypotension (e.g., secondary to regional anesthesia), maternal seizures, fetal scalp sampling, or fetal movement producing transient cord compression. If the fetus was not previously compromised, recovery will usually occur with discontinuation of the inciting event or agent, position change, increased intravenous fluids, maternal oxygen supplementation or a combination of these measures. When accompanied by change in variability, decelerations are more likely to be associated with fetal acid/base abnormalities. Factors known to cause these changes should be sought and corrected.

Overall Assessment slide 38 Having assessed the contraction and the FHR patterns and defined risk, an overall assessment of the situation and management plan should be made. The terms “fetal distress” and “birth asphyxia” are inappropriate and have no place in the assessment. In the past, terms describing the FHR tracing were “reassuring” and “non-reassuring”, but since the recent report from the 2008 NICHD work-

8 — — Chapter E: Intrapartum Fetal Surveillance shop, the assessment of fetal status has been organized into a three-tiered system: Category I, II or III. Management of the mother must be based on clinical context, fetal tracing category and include a plan for further fetal surveillance if labor is allowed to continue. slides 39-40 Generally, Category I tracings are considered normal and can be followed routinely. Category II tracings are indeterminate and not predictive of abnormal fetal pH status. These tracings require prompt evaluation and efforts to resolve the tracing. Category III tracings are clearly abnormal and predictive of abnormal pH status. Prompt evaluation and consideration for immediate delivery is required. The green, yellow, and red Stoplight colors correlate with the NICHD categories.

ACKNOWLEDGEMENT: The ALSO® Program thanks and acknowledges Mr. Kim Hinshaw, MB, BS, FRCOB for the creation of the DR C BRAVADO mnemonic. Mr. Hinshaw is a consultant obstetrician and past chair of ALSO® United Kingdom.

NICHD FHR CLASSIFICATION SYSTEM10 slide 41 Category I FHR tracings Category I tracings are normal tracings that are strongly predictive of normal fetal pH status at the time of observation and must include all of the following: • Baseline of 110 to 160 bpm • Moderate baseline variability • Late or variable decelerations are absent • Early decelerations may be present or absent • Accelerations may be present or absent

slide 42 Category II FHR Tracings Indeterminate tracings are not predictive of fetal acid-base status and cannot be classified as either I or III. The presence of moderate variability or accelerations is highly predictive of normal fetal acid- base status.7 These tracings require prompt evaluation and efforts to resolve the tracing. Category II tracings may show any of the following: • Tachycardia • Baseline with absent, minimal, or marked variability • Recurrent variable decelerations with minimal to moderate variability • Recurrent late decelerations with moderate variability • Variable decelerations with slow return, overshoot or “shoulders” • Prolonged deceleration • No acceleration after fetal stimulation

slide 43 Category III FHR Tracings These tracings are predictive of abnormal fetal pH status. These require prompt evaluation and consideration of immediate delivery. These include: • Sinusoidal pattern OR • Absent FHR variability with any of the following: – Recurrent late decelerations – Recurrent variable decelerations – Bradycardia

— Chapter E: Intrapartum Fetal Surveillance — 9 When using CEFM, tracings should be reviewed by both clinicians and labor and delivery nurses regularly during labor.8 The periodic review includes ensuring that a good quality tracing is present and that abnormalities are appropriately communicated. Some institutions are now using tools for risk management and patient safety including communication strategies. An example would be the SBAR (Situation-Background-Assessment-Recommendation) developed by the Kaiser Permanente Group in Colorado. This technique provides a framework for communication between members of the health care team about a patient’s condition.14

Adequate documentation is necessary and many institutions are now employing flow sheets, clinical pathways or fetal tracing archival processes. Any written information on the tracing, i.e., emergent situations during labor, should coincide with these automated processes to minimize litigation risk.16

Documentation of the fetal heart tracing and categorization during labor should include: 1. Fetal heart rate data (i.e., baseline rate, variability, periodic changes and categorization) 2. Uterine activity characteristics obtained by palpation or pressure transducer (i.e., frequency, duration, intensity and whether tachysystole is present) 3. Specific actions taken when changes in FHR occur 4. Other maternal observations and assessments 5. Maternal and fetal responses to interventions 6. Subsequent return to normal findings

Suggested FHR Management 7 The 2010 ACOG Practice Bulletin on management of intrapartum fetal heart rate tracings presents a standardized approach.7 This is based in part upon the framework developed by Parer,16 who ana- lyzed studies of fetal heart rate tracings to consider four hypotheses: 1. Moderate variability is associated with an absence of acidemia and a non-depressed infant 2. Minimal or absent variability in the presence of late or variable decelerations is associated with acidemia and a depressed infant 3. The depth of the deceleration is directly proportional to infant depression and acidemia 4. After an initial normal FHR tracing, progressive decelerations in the absence of catastrophic events, results in acidemia that develops over a significant amount of time

This study concluded that presence of moderate variability had a 98 percent negative predictive value for the fetal acidosis or an Apgar < 7. Minimal or absent variability with late or variable decelerations was predictive of neonatal acidosis or neonatal depression with 23 percent of neonates having these adverse findings and some evidence that absent variability is more strongly predictive. The depth of decelerations has a stronger association with fetal acidosis for late decelerations than for variable decelerations. Acidosis in the fetus with decreased variability and decelerations was shown to develop slowly over time, except in the setting of a sudden bradycardia as may occur with placental abruption or cord prolapse. In the absence of these potential obstetrical catastrophes there should be at least an hour from the development of decreased variability with decelerations until the development of significant fetal acidosis. As response times for urgent operative delivery varies across maternity care units, the decision point for urgent delivery will be different for each institution.

10 — — Chapter E: Intrapartum Fetal Surveillance Category I EFM Tracings Category I tracings are considered normal and are not associated with fetal acidemia. Recommen- dations are to continue the current monitoring, either intermittent auscultation or electronic fetal monitoring, periodically evaluate and document the clinical status, underlying risk factors and tracings and to change management only if the tracing were to change to a category II or III.

Category II EFM Tracings Category II tracings include all tracings that are not classified as Category I or III. Since these tracings may represent fetal compromise, recommendations are to evaluate and continually survey the tracing, perform appropriate corrective measures when indicated, and then reevaluate. Given that Category II tracings represent such a wide variety of concerns, the presence of accelerations (spontaneous or induced) or moderate variability are useful in predicting fetal well-being (Figure 1). If neither of these characteristics is present after appropriate intrauterine resuscitative measures or if the tracing progresses to a Category III tracing, consider delivery of the infant. If the tracing reverts to a category I after appropriate intervention, then previous monitoring may be initiated or resumed. slide 44 FIGURE 1. Suggested Fetal Heart Rate Management

Assessment of Intrapartum FHR Tracing

Category I Category II* Category III

Routine Management Evaluation and Surveillance Prepare for Delivery + Intrauterine Resuscitative Measures FHR Accelerations Absent FHR or Accelerations and Moderate FHR Absent/Minimal FHR If not improved, Variability Variability consider prompt delivery

Continue Surveillance Intrauterine + Intrauterine Resuscitative Resuscitative Measures Measures

If not Improved or FHR Tracing Progresses to Category III, consider delivery

*Given the wide variation of FHR tracings in Category II, this algorithm is not meant to represent assessment and management of all potential FHR tracings, but provide an action template for common clinical situations.

ACOG Practice Bulletin #116, Management of Intrapartum FHR Tracings, Obstet Gynecol. 2010 Nov; 116(5) 1232-40.

— Chapter E: Intrapartum Fetal Surveillance — 11 Category III EFM Tracings Category III tracings are considered abnormal and recommendations are aimed at correcting fetal acidemia or reducing outcomes of neonatal encephalopathy, cerebral palsy and neonatal acidosis. Preparation for delivery and a time frame for delivery are essential as well as performing intrauterine resuscitative measures. If tracings do not improve with appropriate corrective maneuvers, then prompt delivery of the infant is indicated.

Considerations in preparing for an operative delivery in the setting of a Category III tracing should be made judiciously and expeditiously. The standard rule of “30 minutes from decision-to-incision”, although used frequently, has not been supported in the literature to reduce adverse neonatal outcomes.7 In addition, immediate delivery of an infant with an unknown duration of a Category III tracing, may not improve outcomes if the infant has experienced a pre-existing hypoxic insult.7 slide 45 Intrauterine Resuscitative Measures7 Table 2. Various Intrauterine Resuscitative Measures for Category II or Category III Tracings or Both

Associated Fetal Heart Potential Goal Rate Abnormality* Intervention (s) - Promote fetal oxygenation - Recurrent late cecelerations - Initiate lateral positioning (either and improve uteroplacental - Prolonged decelerations or left or right) blood flow bradycardia - Administer maternal oxygen - Minimal or absent featl heart administration rate variability - Administer intravenous fluid bolus - Reduce uterine activity - Tachysystole with Category II - Reduce uterine contraction or III Tracing frequency - Discontinue osytocin or - Alleviate umbilical cord - Recurrent variable decelerations cervical ripening agents compression - Prolonged decelerations or - Administer tocolytic medication bradycardia (eg, terbutaline) - Initiate maternal repositioning - Initiate amnioinfusion - If prolapsed umbilical cord is noted, elevate the presenting fetal part while preparations are underway for operative delivery

Always: check cervix, maternal vital signs ACOG Practice Bulletin #116, Management of Intrapartum FHR Tracings, Obstet Gynecol. 2010 Nov; 116(5) 1232-40.

Various intrauterine resuscitative measures to be undertaken for category II or III FHR tracings.7 The goals of these corrective measures are aimed at the underlying suspected cause of the abnormality in the FHR tracing. They are also dependent upon the associated fetal heart rate abnormality identified.

Possible interventions include: • Change in maternal positioning to initiate lateral positioning (left or right) • Administer maternal oxygen • Administer intravenous fluid bolus • Reduce uterine contraction frequency

12 — — Chapter E: Intrapartum Fetal Surveillance • Discontinue oxytocin or cervical ripening agents • Administer tocolytic medication • Initiate amnioinfusion • If prolapsed umbilical cord is noted, elevate the presenting fetal part while preparations are made for operative delivery.

Other important areas to consider are: • Assess maternal vital signs • Vaginal exam • Change method of FHR monitoring

Administration of maternal oxygen remains a common intervention supported by one study.17 Tocolysis should be considered, especially in the setting of tachysystole. The use of terbutaline compared to untreated controls showed an improvement in FHR tracings, however, clinical outcomes of perinatal mortality, low five minute APGAR scores and admission to neonatal intensive care units were not improved.18 slide 46 Ancillary testing for Category II and III FHR Tracings Fetal scalp pH testing is no longer commonly performed in the United States and has been replaced with fetal stimulation or immediate delivery (by operative vaginal delivery or cesarean section). A meta-analysis showed that if there is absent or minimal variability without spontaneous accelerations, the presence of an acceleration after scalp stimulation or fetal acoustic stimulation indicates that the fetal pH is > 7.20.19 If the fetal heart tracing remains abnormal then these tests may need to be performed periodically and consideration for emergent cesarean or operative vaginal delivery is usually recommended.11 Cord blood gases are recommended after a delivery for an abnormal fetal heart rate tracing. slide 47 Amnioinfusion Amnioinfusion should be considered for suspected cord compression, to reduce the occurrence of variable heart rate decelerations and lower the use of cesarean delivery in those settings where cesarean delivery is done for abnormal fetal heart rate alone.20 Amnioinfusion has also been shown to be associated with a reduction in the incidence of both neonatal and maternal hospital stay greater than three days. No improvement in long-term neonatal outcomes has been detected.

Although generally considered safe, amnioinfusion carries a few precautions and potential complications. Amnioinfusion is only indicated for recurrent variable decelerations and is not indicated for late decelerations, fetal bradycardia, thick meconium, or oligohydramnios with a normal heart rate tracing.20

Amnioinfusion should also not be attempted when cesarean delivery is indicated, such as in transverse lie or placenta previa. It should never be carried out when doing so would result in a delay of more definitive treatment. With breech presentation or multiple gestation, or when placental abruption is suspected, caution should be taken in performing amnioinfusion. Complications include umbilical cord prolapse, rupture of a previous cesarean scar, amniotic fluid embolism, acute uterine hypertonus with a Category II or Category III fetal heart tracing, and acute polyhydramnios.

— Chapter E: Intrapartum Fetal Surveillance — 13 GUIDELINES FOR PERFORMING AMNIOINFUSION: slides 48-49 Amnioinfusion can be done by either continuous or intermittent technique. A randomized controlled trial showed that there was no difference in between the two for resolving variable decelerations.21

For continuous infusion: 1. Perform a vaginal examination to determine presentation, dilation, and to rule out cord prolapse. 2. Obtain informed consent. 3. Place the patient in the left lateral position. Place an intrauterine pressure catheter (IUPC) and consider placement of a fetal scalp electrode. Use a double lumen catheter, if available, for saline infusion. 4. If a double lumen catheter is not available, attach an 18 - gauge needle to IV tubing connected to normal saline or lactated Ringer’s solution using a blood warmer. Attach extension tubing filled with distilled water between the IUPC and the transducer. Insert the 18 - gauge needle into the side port of the extension tubing. 5. Infuse fluid, giving 250 to 500 ml initially, followed by 50 to 60 ml per hour maintenance infusion until fetal heart rate abnormalities resolve.

*NOTE: Resting tone will be increased while the infusion is running, but elevated baseline tone prior to infusion is a contraindication.

FIGURE 2. Suggested Management of Tachysystole7 slide 50

Uterine Tachysystole

Spontaneous Labor Labor Induction or Augmentation

Category I FHR Tracing Category II or III FHR Tracing Category I FHR Tracing Category II or III FHR Tracing

No Interventions Required Intrauterine Resuscitative Decrease Uterotonics Decrease or Stop Uterotonics Measures*

Intrauterine Resuscitative If no Resolution, Measures* Consider Tocolytic

If no Resolution, Consider Tocolytic

*See Table 2 for list of various intrauterine resuscitative measures. ACOG Practice Bulletin #116, Management of Intrapartum FHR Tracings, Obstet Gynecol. 2010 Nov; 116(5) 1232-40.

14 — — Chapter E: Intrapartum Fetal Surveillance Tachysystole is defined as greater than five contractions over 10 minutes over a 30-minute period. Management of this condition is dependent upon the FHR tracing abnormality. For women with spontaneous labor and a Category I FHR tracing, no intervention is required. If a Category II or III FHR tracing exists, intrauterine resuscitative measures depend on the clinical situation coupled with associated FHR characteristics of variability and accelerations. If labor is induced or augmented, regardless of the FHR tracing categorization, the oxytocin dose should be reduced or if cervical ripening agents are being used, they should be discontinued. If there is the presence of a Category II or III FHR tracing, then initiation of intrauterine resuscitative measures may help to alleviate FHR tracing abnormalities. If tachysystole does not resolve with intervention measures, then tocolytic medication (e.g. terbutaline) should be considered.

slide 51 Areas for Future Development Although CEFM continues to be the “gold” standard for fetal monitoring, active research is being performed to enhance CEFM with computerized interpretation or to develop newer methodologies to monitor fetal well-being during labor.

Fetal hypoxemia results in biphasic changes in the ST segment of the fetal ECG (fECG) waveform and an increase in the T/QRS ratio. The ST segment automated ANalysis (STAN, Neoventa Medical, Goteberg, Sweden) software can record the frequency of ST events and combined with changes in CEFM can be used to determine if intervention during the labor process is indicated. Several studies have evaluated fECG analysis documenting the effectiveness to reduce operative vaginal deliveries, fetal scalp sampling, neonatal encephalopathy and fetal acidosis (pH < 7.05).22-25 One drawback to this technology is that it requires rupture of the membranes and internal fetal scalp monitoring.

Another area of research is the use of computer analysis of key components of the fetal tracing26-28 or decision analysis for the interpretation of the EFM tracing.29 These have not been demonstrated to improve clinical outcomes.

Fetal pulse oximetry was developed using an internal monitor, requiring rupture of membranes, to continuously monitor fetal oxygenation during labors.30-32 Trials have not demonstrated significance differences in reducing cesarean section rates or interventions with the use of fetal oximetry.

slide 52 SUMMARY Initiation of fetal monitoring begins with assessment of maternal and fetal risk. Since CEFM has a low positive predictive value and can result in increased rates of cesarean delivery, intermittent auscultation is recommended for low risk pregnancies. However, staff availability and experience must be considered before deciding on this technique. Providers should be ready to change monitoring to CEFM if a high-risk situation develops.

If CEFM is selected for fetal surveillance, interpretation needs to be done in light of the clinical background, the overall pattern, stage of labor, and in conjunction with fetal scalp or acoustic stimulation. This combination maximizes the benefit to infant without increasing operative delivery rates. Outcomes may still be unaffected using this technique, even in high-risk pregnancies. Efforts have recently been undertaken to standardize the definitions, interpretation and general management of FHR tracings. It is critical that institutions and hospitals insure that all labor and delivery personnel

15 — — Chapter E: Intrapartum Fetal Surveillance are trained in these categorization rankings. Communication among team members is also critical and tools or strategies to maximize accuracy and completeness of transfer of information should be utilized (i.e. SBAR) to minimize medical errors and for patient safety.

Regardless of which technology is employed, the patient/support relationship is paramount during the labor process. Providers should not allow any monitoring approach to substitute for personal attention to mother and fetus throughout labor.

If your institution has a risk management or patient safety committee, regular monitoring and compliance with all aspects of fetal surveillance should be undertaken. The team should be composed of physicians, nurses, administrators and all other pertinent staff for successful implementation.

SORT: KEY OF RECOMMENDATIONS FOR PRACTICE Clinical Recommendation Evidence Rating Reference Structured intermittent auscultation should be offered to low risk women as an alternative to continuous electronic fetal monitoring (CEFM). CEFM does not decrease perinatal mortality. CEFM reduced neonatal seizures (NNT= 661) but does A 2 not reduce the incidence of cerebral palsy. CEFM increased cesarean section rates (overall) (NNT = 20) and instrumental vaginal births (NNT = 33).

The presence of moderate fetal heart rate variability is predic- B 7, 16 tive of normal fetal acid-base status.

A category III fetal monitoring tracing increases the likelihood of fetal acidosis and requires prompt measures for intrauter- B 7, 16 ine resuscitation and consideration of the need for urgent delivery if these measures do not result in improvement.

A period of CEFM upon maternity unit admission versus auscultation results in significant increased interventions includ- A 5 ing epidural analgesia (NNT = 19), CEFM (NNT = 7) and fetal blood scalp testing (NNT = 45).

Compared to EFM alone, the addition of fECG analysis results in a reduction in operative vaginal deliveries A 22 (NNT = 50) and fetal scalp sampling (NNT = 33).

Amnioinfusion for umbilical cord compression in the presence of decelerations reduced fetal heart rate decelerations (NNT = 3), cesarean section overall (NNT = 8), Apgar score less than seven at five minutes (NNT = 33), low cord arterial A 20 pH (< 7.20) (NNT = 8), neonatal hospital stay greater than three days (NNT = 5) and maternal hospital stay greater than three days (NNT = 7).

16 — — Chapter E: Intrapartum Fetal Surveillance SUMMARY TABLE CEFM Findings Significance Management Category I Normal Moderate variability, no Normal pH and fetal well-being - Continue current monitoring method decelerations, accelerations and (structured intermittent auscultation normal baseline [SIA] or continuous electronic fetal monitoring [CEFM]) Category II Indeterminate Baseline changes Tachycardia – Medication (terbutaline, - Intrauterine Resuscitative Measures (bradycardia or tachycardia) cocaine or other stimulants), maternal aimed at promoting fetal oxygenation or prolonged deceleration anxiety, infection (chorioamnionitis, and improving uteroplacental blood flow Baseline changes (bradycardia pyelonephritis or other maternal infection), - Evaluate fetal heart rate variability or tachycardia) or prolonged fever, maternal medical disorders deceleration (hyperthyroidism), obstetrical conditions - Consider prompt delivery (assisted (placental abruption or fetal bleeding, fetal vaginal or cesarean section) for tachyarrythmias bradycardia with minimal or absent variability or prolonged decelerations or Bradycardia – rupture of membranes, both that do not resolve occiput-posterior, post-date pregnancy, congenital anomalies, maternal hypotension, umbilical cord prolapse, rapid fetal descent, tachysystole, placental abruption or uterine rupture achycardia –ure Change in variability (minimal) Medications (opioid or magnesium sulfate); - For possible decreased oxygenation, should resolve in one to two hours Intrauterine Resuscitative Measures aimed at promoting fetal oxygenation and improving uteroplacental blood flow Sleep cycle (generally lasts 20 minutes but - No improvement and no FHR can persist up to 60 minutes) accelerations then digital scalp or vibroacoustic stimulation Possible fetal hypoxia / acidemia - Consider prompt delivery (assisted vaginal or cesarean section) if fetal acidemia is suspected and unresolved Decelerations without absent Intermittent Variable Decelerations – - Intrauterine Resuscitative Measures variability common and do not require treatment aimed at relieving umbilical cord compression Recurrent Variable Decelarations- evaluate frequency, depth and duration. The presence of moderate FHR variability or spontaneous or induced accelerations suggests no acidemia. Late Deceleration– maternal hypotension - Intrauterine Resuscitative Measures (ie., postepidural), uterine tachysystole, and aimed at promoting fetal oxygenation maternal hypoxia. and improving uteroplacental blood flow - Reevaluate for improvement of FHR tracing (accelerations or moderate variability) - Consider prompt delivery (assisted vaginal or cesarean section) if no accelerations or minimal variability and late decelerations persist.

17 — — Chapter E: Intrapartum Fetal Surveillance Category III Abnormal Absent baseline variability and Uteroplacental insufficiency Intrauterine Resuscitative Measures recurrent decelerations (variable aimed at promoting fetal oxygenation and Fetal hypoxia / acidemia or late) improving uteroplacental blood flow - Prepare and consider time frame for delivery (30 minute rule) - Consider prompt delivery (assisted vaginal or cesarean section) for unresolved FHR tracings Tachysystole Uterine tachysystole Spontaneous labor with Category II or III - Intrauterine Resuscitative Measures FHR tracing aimed at reducing uterine activity - If no resolution, consider tocolytic

Labor induction or augmentation and - Decrease uterotonics Category I FHR tracing

Labor induction or augmentation and - Decrease or stop uterotonics Category II or III FHR tracing - Intrauterine Resuscitative Measures aimed at reducing uterine activity - If no resolution, consider tocolytic * See Table 2 “Intrauterine Resuscitative Measures

18 — — Chapter E: Intrapartum Fetal Surveillance REFERENCES 1. Martin JA, Hamilton BE, Sutton PD, et al. Births: final data for 17. Haydon ML, Gorenberg DM, Nageotte MP, et al. The effect of 2002. Natl Vital Stat Rep. 2003 Dec 17;52(10):1-113. maternal oxygen administration on fetal pulse oximetry during labor in fetuses with nonreassuring fetal heart rate patterns. Am 2. Alfirevic Z, Devane D, Gyte GM. Continuous cardiotocography J Obstet Gynecol. 2006 Sep;195(3):735-8. (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour. Cochrane Database Syst Rev. 2006 18. Kulier R, Hofmeyr GJ. Tocolytics for suspected intrapartum fetal Jul 19;3:CD006066. distress. Cochrane Database Syst Rev. 2000;(2):CD000035. 3. Chauhan SP, Klauser CK, Woodring TC, et al. Intrapartum 19. Skupski DW, Rosenberg CR, Eglington GS. Intrapartum fetal nonreassuring fetal heart rate tracing and prediction of adverse stimulation tests: a metaanalysis. Obstet Gynecol. 2002 outcomes: intraobserver variability. Am J Obstet Gynecol. 2008 Jan;99(1):129-34. Dec;199(6):623.e1-5. 20. Hofmeyr GJ. Amnioinfusion for potential or suspected umbilical 4 Confidential Enquiry into Stillbirths and Deaths in Infancy: cord compression in labour. Cochrane Database of Systematic 4th Annual Report 1997. London: Maternal and Child Health Reviews 2000, Issue 2. Research Consortium; 1997 1st January - 31st December 1995. 21. Rinehart BK, Terrone DA, Barrow JH, et al. Randomized trial of 5. Bix E, Reiner L, Klovning A, Oian P. Prognostic value of the intermittent or continuous amnioinfusion for variable decelera- labour admission test and its effectiveness compared with aus- tions. Obstet Gynecol. 2000 Oct;96(4):571-4. cultation only: a systematic review. BJOG 2005;112: 1595– 604. 22. Neilson JP. Fetal electrocardiogram (ECG) for fetal monitor- 6. American College of Obstetricians and Gynecologists. ing during labor. Cochrane Database Syst Rev. 2006 Jul ACOG Practice Bulletin No. 106: Intrapartum Fetal Heart 19;3:CD000116. Rate Monitoring: Nomenclature, Interpretation, and General 23. Devoe LD, Ross M, Wilde C, et al. United States multicenter Management Principles. July 2009;114(1):192-202. clinical usage study of the STAN 21 electronic fetal monitoring 7. American College of Obstetricians and Gynecologists, ACOG system. Am J Obstet Gynecol. 2006 Sep;195(3):729-34. Practice Bulletin No 116: Management of Intrapartum Fetal 24. Vayssiere C, Haberstich R, Sebahoun V, et al. Fetal electrocar- Heart Rate Tracings. Nov 2010; 116(5):1232-1240. diogram ST-segment analysis and prediction of fetal acidosis. 8. Liston R, Sawchuck D, Young D; Society of Obstetrics and Int J Gynaecol Obstet. 2007 May;97(2):110-4. Gynaecologists of Canada; British Columbia Perinatal Health 25. Ojala K, Vääräsmäki M, Mäkikallio K, et al. A comparison of Program. Fetal health surveillance: antepartum and intrapartum intrapartum automated fetal electrocardiography and conven- consensus guideline. J Obstet Gynaecol Can. 2007 Sep;29(9 tional cardiotocography--a randomised controlled study. BJOG. Suppl 4):S3-56. 2006 Apr;113(4):419-23. 9. Electronic fetal heart rate monitoring: research guidelines for 26. Greene MF. Obstetricians still await a deus ex machine. N Engl interpretation. National Institute of Child Health and Human J Med. 2006 Nov 23;355(21):2247-8. Development Research Planning Workshop. Am J Obstet Gynecol. 1997 Dec;177(6):1385–90. 27. Salamalekis E, Hintipas E, Salloum I, et. al. Computerized analysis of fetal heart rate variability using the matching pur- 10. Macones GA, Hankins GD, Spong CY, et al. The 2008 National suit technique as an indicator of fetal hypoxia during labor. J Institute of Child Health and Human Development workshop Matern Fetal Neonatal Med. 2006 Mar;19(3):165-9. report on electronic fetal monitoring: update on definitions, interpretation, and research guidelines. Obstet Gynecol. 2008 28. Giannubilo SR, Buscicchio G, Gentilucci L, et al. Deceleration Sep;112(3):661-6. area of fetal heart rate trace and fetal acidemia at delivery: a case control study. J Matern Fetal Neonatal Med. 2007 11. Parer JT, Ikeda T. A framework for standardized management Feb;20(2):141-4. of intrapartum fetal heart rate patterns. Am J Obstet Gynecol. 2007 Jul;197(1):26.e1-6. 29. Westgate JA, Wibbens B, Bennet L, et al. The intrapartum deceleration in center stage: a physiologic approach to the 12. Hinshaw K, Ullal A. Peripartum and intrapartum assessment interpretation of the fetal heart rate changes in labor. Am J of the fetus. Anaesthesia & Intensive Care Medicine. 2007 Obstet Gynecol. 2007 Sep;197(3):236.e1-11. Aug;8(8):331-6. 30. East CE, Brennecke SP, King JF, et al. The effect of intrapartum 13. Low JA, Victory R, Derrick EJ. Predictive value of electronic fetal pulse oximetry, in the presence of a nonreassuring fetal fetal monitoring for intrapartum fetal asphyxia with metabolic heart rate pattern, on operative delivery rates: a multicenter, acidosis. Obstet Gynecol. 1999 Feb;93(2):285-91. randomized, controlled trial (the FOREMOST trial). Am J Obstet 14. Leonard M. Situation-Background-Assessment-Recommendation Gynecol. 2006 Mar;194(3):606.e1-16. (SBAR). Kaiser Permanente of Colorado 31. Bloom SL, Spong CY, Thom E, et al. Fetal pulse oxim- 2009. http://www.ihi.org/IHI/Topics/PatientSafety/ etry and cesarean delivery. N Engl J Med. 2006 Nov SafetyGeneral/Tools/ BARTechniquefor 23;355(21):2195-202. CommunicationASituationalBriefingModel.htm 32. East CE, Chan FY, Colditz PB, Begg LM. Fetal pulse oximetry 15. Chez BF. Electronic fetal monitoring then and now. J Perinat for fetal assessment in labour. Cochrane Database Syst Rev. Neonatal Nurs. 1997 Mar;10(4):1-4. 2007 Apr 18;(2):CD004075. 16. Parer JT, King T Flanders S, Fox M, et al.Fetal acidemia and fetal heart rate patterns: Is there evidence of an association? J Maternal-Fetal and Neonatal Medicine. 2006 May;19(5):289-294.

19 — — Chapter E: Intrapartum Fetal Surveillance Chapter F Labor Dystocia Sara G. Shields, MD, MS Stephen Ratcliffe, MD, MSPH

Published June 2014

OBJECTIVES After completing this chapter, participants will be able to: 1. Define the difference between normal labor and labor dystocia. 2. Describe common etiologies for dystocia. 3. Describe how to diagnose and treat dystocia. 4. Discuss prevention methods.

INTRODUCTION Caring for women with dystocia, literally “difficult labor,” is one of the greatest challenges of maternity care. While this particular labor difficulty may not have the same emergent need for treatment that other clinical scenarios in the ALSO® course have, maternity providers nonetheless face dystocia frequently and can improve clinical outcomes with appropriate, evidence-based care. This chapter reviews important new concepts in the diagnosis, treatment, and prevention of dystocia.

Dystocia refers to prolonged or slowly-progressing labor, a common situation for nulliparous women as gauged by the number that require augmentation, operative vaginal delivery, or cesarean section. In 2008, about 20 percent of women in the United States received oxytocin augmentation and the primary cesarean delivery rate (cesarean delivery in women without a prior cesarean) in the 27 states reporting this data rose to 23.8 percent (see Figure 1).1 Dystocia is responsible for between 30 and 50 percent of primary cesarean deliveries in the United States.2,3 With the overall US cesarean delivery rate at over 32 percent (see Figure 2), attention is focusing on the two labor issues that are the main drivers of the primary cesarean rate, dystocia and non-reassuring fetal heart tracing.3,5 The wide variation in cesarean rates for these indications among low-risk women suggests, as with any medical outcome with substantial variability, the need for more thoughtful, evidence-based care for a woman with labor dystocia.3,5,6 All maternity care providers need expertise in the care of women experiencing dystocia.

— Chapter F: Labor Dystocia — 1 Figure 1. Total and Primary Cesarean Rate and vaginal Birth After Previous Cesarean (VBAC): United States, 1989-20122

Data are not available to delineate national trends in rates of primary cesarean section and vaginal birth after cesarean (VBAC) from 2005 onward, due to differences in adoption of the revised (2003) birth certificate form. The above data are provided to help understand recent patterns of use but should not be used to compare figures from year to year due to the changing cohorts using the revised 2003 form.

2 — — Chapter F: Labor Dystocia RETHINKING LATENT LABOR Understanding normal and abnormal labor progress requires understanding latent or prodromal labor, so as to avoid performing cesareans during a prolonged latent phase that is mistaken for active labor. Latent phase labor occurs when there are regular painful contractions that result in minimal or slow cervical change. Another definition is that latent phase of labor begins with maternal perception of painful contractions and ends when the rate of dilation begins to accelerate.8

Recent studies suggest that normal labor may have a longer latent phase and thus a wider time range and a less clear-cut transition to active labor than previously defined by Friedman in the 1950’s.8 Re-analysis of data from the large National Collaborative Perinatal Project from the 1960s, when fewer obstetric interventions were practiced has allowed the normal course of natural spontaneous labor to be better defined. This reanalysis found that the active phase of labor, when rapid dilation begins, may not start for multiparous women until at least 5 cm of dilation and for nulliparous women at an even greater dilation that is harder to define.10 Similar data in today’s women suggest that the active phase of labor may not occur for multiparous women until closer to 6 cm dilation.11

Not only is the start of active labor later and harder to define than previously thought, the rate of change in active dilation, while accelerating in active labor, may also be longer than in prior studies. In Laughon’s study, after 6 cm dilation, nulliparous women took an average of 2.2 hours to reach full dilation, with the 95th percentile standard deviation at 10.1 hours, or less than 0.5 cm per hour compared to Friedman’s outer limit of progress for nulliparas of 1.2 cm per hour in active phase.11 (See Table 1)

Table 1. Stages of Labor: Normal Variation

Nulliparous Multiparous

Median 1.8 cm/hr Median 2.5 cm/hr Rate of dilation in active labor (95% SD 0.4 cm/hr) (95% SD 0.4 cm/hr)

2nd stage duration Median 0.9hr (95% SD 3.1 hr) Median 0.3hr (95% SD 1.7 hr)

Adapted from Laughon 2012 and Sponge 2012

The clinical dilemma is that many women are inadvertently admitted prior to progressive labor yet held to traditional dilation expectations of active labor,12 thus resulting in a misdiagnosis of labor dystocia with a resultant cascade of interventions that increase the risk of cesarean section. Clinicians need to recognize that cervical dilation is not linear, particularly early in labor for nulliparous women.10

To prevent, the mis-diagnosis of labor dystocia in women who are still in the latent phase, the clinician can avoid admitting women too early to the hospital.13 Such a practice reduces by more than half the risk of needing augmentation of labor or epidural analgesia.14 As alternatives to admission in latent labor, clinicians can encourage adequate hydration, rest, emotional and physical support, and if needed, pharmacologic sedation such as antihistamines or opiates such as morphine.15

For women who are admitted before active labor, patience is the critical factor. This is especially important before 6 cm of dilation. Options for care for women admitted between 3 and 6 cm of

— Chapter F: Labor Dystocia — 3 dilation include an antepartum unit for rest and support, including the availability of pharmacologic treatment for exhaustion as discussed above. There should be clear maternal or fetal indications to augment labor during the latent phase8 to justify the risks associated with oxytocin augmentation such as uterine tachysystole, fetal intolerance of labor and increased rates of operative intervention.16 As discussed below, latent labor may be longer in women undergoing labor induction than in women in spontaneous labor. Cesarean for dystocia should not be done if women are still in latent labor.2

DIAGNOSIS OF DYSTOCIA Contemporary studies lead to new definitions of arrested labor.

Table 2. Definitions of Failed Induction and Arrest Disorders

FAILED INDUCTION OF LABOR Failure to generate regular (eg. Every 3 min) contractions and cervical change after at least 24 hr of oxytocin administration, with artificial membrane rupture if feasible

FIRST-STAGE ARREST 6 cm or greater dilation* with membrane rupture and no cervical change for 4 hr or more of adequate contractions (eg. > 200 Montevideo units) or 6 hr or more if contractions inadequate

SECOND-STAGE ARREST No progress (descent or rotation) for 4 hr or more in nulliparous women with an epidural 3 hr or more in nulliparous women without an epidural 3 hr or more in multiparous women with an epidural 2 hr or more in multiparous women without an epidural

*Since women may still be in latent labor, additional time and interventions may be needed in order to diagnose an arrest of active labor before 6 cm dilation (see Figure 1 for suggested management).

Once the clinician ascertains that a woman has reached active labor (5 to 6 cm of dilation), the rate of change may accelerate (Table 3), although patience about the rate of dilation remains important.2,10

Table 3. Duration of Each Centimeter Change in Cervical Dilatation for Nulliparous Women with Spontaneous Onset of Labor* Cervical Change (cm) Median (h) 95th Percentile (h)

3 to 4 1.8 8.1 4 to 5 1.3 6.4 5 to 6 0.8 3.2 6 to 7 0.6 2.2 7 to 8 0.5 1.6 8 to 9 0.5 1.4 9 to 10 0.5 1.8

*Modified from Zhang J, Landy HJ, Branch DW, Burkman R, Haberman S, Gregory KD, et al. Contemporary patterns of spontaneous labor with normal neonatal outcomes. Obstet Gynocol 2010; 115:1281-7.

4 — — Chapter F: Labor Dystocia Thus, clinical dystocia can be defined at different points depending on how dilated a woman is: for instance, if she is less than 5 cm dilated, dystocia is the diagnosis if she is progressing less than 0.3 to 0.4 cm per hour. If she is 8 cm dilated, dystocia occurs if she is progressing less than 0.7 cm per hour. As part of making this diagnosis, the clinician needs to address the following questions: • Are contractions adequate? • Is there a malposition or malpresentation? • Is there cephalopelvic disproportion due to suspected macrosomia or a contracted pelvis? • Are there other co-existing clinical issues such as chorioamnionitis or non-reassuring fetal monitoring that impact on the treatment choices?

TREATMENT OF ACTIVE-PHASE DYSTOCIA First Stage Active-Phase Dystocia Treatment strategies for women with slowly-progressing labor traditionally have included amniotomy, pharmacologic augmentation with oxytocin, or both. Amniotomy alone: A meta-analysis showed that women of any parity undergoing amniotomy alone were less likely to have non-progressing labor than women who did not (RR 0.75, 95% CI 0.64 to 0.88); similarly, women who underwent amniotomy routinely were less likely to need oxytocin augmentation (RR 0.73, 95% CI 0.57 to 0.95). Nulliparous women who had amniotomy had a slightly shorter second stage of labor than those who did not (but only by one to ten minutes). However, routine amniotomy alone in spontaneous labor did not change overall first stage labor length, or cesarean section rates.17 Pharmacologic augmentation: Oxytocin alone may not change outcomes, either. Although the overall duration of labor may shorten in women who receive oxytocin early in labor for slow labor, this intervention alone does not ultimately change the cesarean rate.18 Both amniotomy and pharmacologic augmentation: Combining amniotomy with oxytocin may be the most effective augmentation strategy. In trials of prevention strategies for labor dystocia, early augmentation with both amniotomy AND oxytocin was associated with a modest reduction in the number of caesarean births (RR 0.87; 95% CI 0.77 to 0.99) and a shortened duration of labor (average mean difference (MD) - 1.28 hours; 95% CI -1.97 to 0.59). In this analysis, the number needed to treat (NNT) to prevent one cesarean by using amniotomy and oxytocin together early in labor was 65.19

For women with protracted or arrested active phase labor, the clinician can evaluate the strength and frequency of uterine contractions by abdominal palpation or an intrauterine pressure catheter (IUPC), which allows calculation of Montevideo units (MVU) (see Figure 2). Two hundred or more MVU in 10 minutes is considered evidence of adequate contractions.20 Using an IUPC may be most important if contractions seem to be of sufficient frequency and duration but are not causing the expected cervical change. However, a meta-analysis concluded that the use of an IUPC does not appear to change labor duration or cesarean rates.21 The use of an IUPC may increase the risk of maternal fever22 so should not be routine.

— Chapter F: Labor Dystocia — 5 Figure 2.

If contractions are inadequate, administering intravenous oxytocin increases contraction frequency, duration, and strength. There are numerous approaches to dosage, dosing interval, and duration of oxytocin treatment. Low-dose regimens, which attempt to mimic the known steady-state pharma- codynamics of oxytocin, start at 1.0 to 2.0 mU/min and increase by 1 to 2 mU/min every 30 minutes to maximum doses of 36 mU/min.20 High-dose regimens were compared to the low-dose regimens in a prospective cohort study of 15,054 women. This study defined high-dose oxytocin as a starting dose of 4 mU/min with incremental increases of 4 mU/min up to maximum of 36 mU/min.23 High- dose oxytocin resulted in shorter labors in both nulliparous and multiparous women but did not decrease cesarean section rates.

Appendix 1 lists sample oxytocin orders. Any use of oxytocin is usually combined with the routine use of continuous electronic fetal heart rate monitoring or the use of structured intermittent fetal auscultation every 15 minutes in stage one and every five minutes in stage two.24 Oxytocin is a drug with the potential for adverse effects,16 so its use should be reserved for clearly defined indications.

Once oxytocin has been started to augment slow labor, recent studies again suggest the need for a more patient approach in monitoring labor progress.2 Assuming fetal well-being, the clinician and woman should wait at least four hours of adequate contractions following oxytocin augmentation before operative intervention for arrested dilation: such an approach can significantly lower the cesarean rate for arrest of labor from 26 percent to eight percent.25,26 Expectant management for longer time frames (e.g. six hours) is under study to assess the potential for increasing risk of complications such as chorioamnionitis and postpartum hemorrhage as labor duration increases.

In clinical practice, it is sometimes challenging to separate out whether a cesarean section is being done for lack of labor progress or for fetal intolerance to oxytocin needed to effect that progress. Clinicians should follow the NICHD categories of FHR monitoring to classify abnormalities (Chapter E. Intrapartum Fetal Surveillance).

6 — — Chapter F: Labor Dystocia Second Stage Dystocia Dystocia can also occur in the second stage of labor and is characterized by prolonged duration or arrest of descent. The median duration of second stage lasts longer for nulliparous women than traditionally defined with the 95th percentile at 2.8 hours without regional anesthesia and 3.6 hours with regional anesthesia.2 For multiparous women, the 95th percentiles for second-stage duration with and without regional anesthesia remained around two and one hour, respectively.10 Studies on the neonatal and maternal effects of prolonged second stage yield mixed results,27 although the likelihood of vaginal delivery diminishes once second stage lasts past the time frames noted above.28,29 Prolongation of the second stage beyond an arbitrary time limit is no longer an indication for operative vaginal or cesarean delivery. When the second stage is prolonged it is important to evaluate if progress is occurring, chorioamnionitis has developed or there are concerns regarding fetal monitoring

Second stage dystocia may be due to fetal malposition, inadequate contractions, poor maternal efforts or true cephalopelvic disproportion. Each of these possible causes has potential management options.

Fetal Malposition: The most common fetal malposition is occiput posterior (OP), where the fetus lies with its occiput toward the mother’s spine and its face toward the mother’s pubic symphysis. Persistent OP is associated with prolonged second stage labor and an increased need for oxytocin augmentation.30 The clinical care of women with persistent OP position, including the technique of manual rotation of a fetus from OP to OA position, is described in Chapter G: Malpresentations, Malpositions, and Multiple Gestation.

For a laboring woman without an epidural, her position during second stage does not appear to affect its duration significantly,31 but if she stays more upright, this position may reduce the risk of both abnormal fetal heart rate tracings (RR 0.46; 95% CI 0.22 to 0.93) and assisted vaginal delivery compared to the supine position (RR) 0.78; 95% CI 0.68 to 0.90), with a possible increased risk of postpartum hemorrhage if upright compared to supine (RR 1.65; 95%CI 1.32 to 2.06). Studies of the effects of upright position for women with an epidural are inconclusive.32 Thus women in the second stage with or without an epidural should be allowed to assume whatever position is most comfortable for them.

Inadequate contractions: Just as in first-stage dystocia, if contractions have decreased in strength or frequency during the second stage, pharmacologic treatment with oxytocin may be necessary. Thus when fetal descent has slowed in the second stage, the clinician may need to initiate or increase intravenous oxytocin.33,34

Maternal exhaustion: Exhaustion can affect the length of second stage labor. For women with epidural analgesia, an alternative to initiating active pushing at full cervical dilation is allowing the fetus to “labor down” to a lower station, or delaying pushing for up to 60 to 90 minutes until the mother feels an urge to push or the fetus is at the introitus. This may be especially important for nulliparous women. While such delayed pushing may shorten the active phase of labor and lead to more spontaneous deliveries,35 the overall length of second stage increases along with the risk of maternal fever. If the contractions are farther than three minutes apart then the addition of oxytocin should be considered during the “laboring down” process.34

— Chapter F: Labor Dystocia — 7 During a long second stage, the clinician should remain vigilant to ongoing assessment of fetal well- being. Preventing vena caval compression by moving the mother out of the dorsal lithotomy position and allowing adequate periods of rest between pushing are two basic strategies to prevent fetal intolerance of second stage labor. Repetitive deep variables in the second stage do not necessarily indicate fetal acidosis. If the fetal heart tracing nonetheless deteriorates with the ominous combination of minimal/absent variability and repetitive late or variable decelerations, the clinician should institute measures of fetal resuscitation as described in Chapter E (Intrapartum Fetal Surveillance) while expediting delivery via assisted vaginal delivery or cesarean section.

PREVENTION Maternity providers can attempt to prevent dystocia with the following antepartum and intrapartum strategies: undertaking prenatal interventions to decrease the incidence of fetal macrosomia, provision of labor support, avoidance of elective induction with an unripe cervix, judicious use of epidural analgesia, and prevention of chorioamnionitis

Obesity Maternal obesity, particularly in association with excessive maternal weight gain during pregnancy or with gestational diabetes, increases the risk of fetal macrosomia, which may in turn predispose women to prolonged labor and operative outcomes.36 Dietary counseling during prenatal care can help overweight and obese women limit their weight gain,37,38 and has been shown to decrease the risk of shoulder dystocia, but has not yet been shown to specifically change the rate of macrosomia. Clinicians should thus provide counseling and initiate referrals to nutritionists for these at-risk women. Induction for macrosomia alone is not indicated and has been shown to increase the risk of cesarean compared to expectant care in the nondiabetic woman.39

Clinicians should follow the same initial guidelines for recognition and treatment of dysfunctional labor for obese women as for non-obese women. However, patience with slower labor progress in obese women is important. In one study, overweight and obese nulliparas had significantly longer active phases of labor than women of normal weight.40 Another retrospective study confirmed that obese women have slower progress especially in the early part of active labor.41 Induction with prostaglandins also appears to take longer in obese women.42

Labor Support Meta-analysis of studies of providing trained labor support companions (doulas) demonstrate a decrease in the incidence of dystocia, operative vaginal deliveries, and cesarean deliveries, particularly for first-time mothers.43 The greatest effect on labor comes when trained lay people rather than hospital employees are used, when epidural analgesia is not routinely used, and when support begins in early labor.44 A potential low-cost alternative is for women to choose a female friend or family member to receive specific brief labor support training as part of prenatal care and to accompany the woman in labor; in one trial, this strategy led to shorter overall labors44 although no difference in cesarean rates. For further information about doula programs, see footnote45 and appendix.

8 — — Chapter F: Labor Dystocia Hydration during active labor may prevent prolonged labor. Two randomized trials of intravenous hydration, one in prolonged labor and one in normal labor, suggested shorter labors, less oxytocin use, and a reduced risk of cesarean in women receiving a higher rate (250cc/hr) of IV fluids than traditionally used (125cc/hr).46,47 However, if women have unrestricted oral intake during labor, such IV hydration may not make a difference in these outcomes.48

The role of induction: In contemporary obstetric care, almost one quarter of women in the United States undergo induction of labor.4 The number of births involving induction of labor has more than doubled in the last decade, from nine percent in 1989 to over 23 percent in 2010. Clinicians should avoid induction of women for non-medical indications.49,50

Elective induction may be partially responsible for the increasing rate of cesarean delivery for labor dystocia. Elective induction may result in a two- to three-fold increased risk of cesarean delivery in nulliparous women with an unripe cervix, despite the use of cervical ripening agents.51,52,53 Cochrane reviews of vaginal misoprostol, vaginal prostaglandin and mechanical methods for cervical ripening found that these agents decrease the length of labor but do not change the overall cesarean delivery rate for dystocia;54,55,56 oral misoprostol for induction may lead to fewer cesareans, however.57 In contrast, various studies demonstrated a decreased cesarean rate through selective induction of women at or near term with specific risk factors for developing cephalopelvic disproportion or uteroplacental insufficiency;58,59,60 this style of management includes patient-centered care and patience with cervical ripening which may partially explain the favorable cesarean delivery rates . Because of the increased risk of labor dystocia, induction should be done only for clear maternal or fetal indications.2 Elective induction without medical indication should only be done after 39 weeks’ of gestation50 and is best reserved for multiparous women with a favorable cervix.51

With the goal of vaginal delivery, induction requires patience in allowing adequate time for progress in latent and active labor. Several studies confirm the clinical safety of allowing women undergoing induction to have a latent phase of labor of at least 12 hours after ruptured membranes of labor.62 Particularly for nulliparous women before 6 cm of dilation, induced labor takes longer than spontaneous labor, with one retrospective study concluding that each cm of dilation before 6 cm could take between two and 5.5 hrs longer with induced labor than for spontaneous labor.63 Thus a “failed induction” should be diagnosed only when a woman has not had regular (every three minutes) contractions with cervical change after at least 24 hours of oxytocin administration,2 assuming fetal well-being throughout this time.

Epidural Anesthesia: Although meta-analyses consistently find no difference in cesarean delivery rates among women receiving low-dose epidurals compared to parenteral opioids,64 epidural analgesia does impact labor progress and other outcomes. Women receiving epidurals are more likely to require oxytocin augmentation in the first stage of labor, have longer second stages, have a six-fold increase in the incidence of maternal fevers, have increased incidence of persistent OP malposition, and undergo more operative vaginal deliveries.64,65

— Chapter F: Labor Dystocia — 9 Whether administering epidural analgesia early in labor (prior to 4 to 5 cm dilation) increases the risk for cesarean delivery has been controversial.66 Epidural analgesia is not a single entity, and randomized controlled trials that have specifically investigated early versus standard placement are either small or do not use contemporary low-dose techniques.67 The study most commonly cited to support the use of “early epidurals” actually compared a combined spinal epidural analgesia (CSE) technique (intrathecal opioid given at two centimeters cervical dilation) to epidural given at 4 cm or later. This study found no significant differences in labor duration or rates of cesarean delivery.67

Maternal request is sufficient indication for pain relief during labor,68,69 and epidurals are associated with significantly lower pain scores compared to systemic opioids.64 Clinicians should indi- vidualize whether and when to administer epidural analgesia. Women with significant pain early in labor should not be required to reach 4 to 5 cm prior to epidural placement.69 Conversely, a woman who is informed and prepared to handle labor pain with lesser interventions should not be subjected to the expectation of a “routine epidural.” Clinicians should also support the availability of other pain-relief options such as water immersion,70 nitrous oxide,71,72 and sterile water injec- tions73 that may have less impact on labor duration.

If a woman is having severe “back labor,” feeling her contractions most intensely in her back, this may indicate a persistent OP position. If changing maternal position does not relieve this discomfort, another option for pain relief before resorting to regional anesthesia is to try sterile water injections (Appendix 2). How effective such injections are in reducing pain or changing cesarean rate is debatable; one review found studies inconclusive, while another with slightly different trials included, found that sterile water injections for low back pain in labor reduced pain for up to two hours and reduced the risk of cesarean (RR 0.51 (95% CI 0.30, 0.87) compared to alternative thera- pies (although the overall cesarean rate was below 10 percent in the comparison therapy group).73

Infection Chorioamnionitis is associated with an increased incidence of labor dystocia (adjusted odds ratio 2.3, CI 2.0 to 2.7, for first stage labor and OR 1.8, CI 1.5 to 2.2, for second stage labor) and cesarean delivery (adjusted OR 1.8, CI 1.5-2.1).75 In the setting of premature rupture of the membranes at term (TPROM), the two factors with the greatest association with an increased risk of chorioamnionitis are the length of time between the first digital vaginal exam and delivery and the total number of vaginal examinations over five. Clinicians should delay the initial digital vaginal exam and substitute a sterile speculum exam in the patient with TPROM who is not laboring. Attempts should be made to limit the total number of vaginal exams after rupture of membranes to five or less,76 although more recent studies suggest less risk than previously thought.77

Ambulation Women who walk or remain upright during the first stage of labor report greater comfort and ability to tolerate labor compared to women who remain recumbent.78 A randomized trial comparing women assigned to walk in early labor to those receiving usual care showed no differences in the duration of the first stage, need for oxytocin augmentation, use of analgesia, or rates of operative vaginal or cesarean delivery.79 Although walking in labor did not decrease dystocia in this study that had several methodologic issues80 ambulation can offered safely as there were no harmful effects for mothers or infants.79

10 — — Chapter F: Labor Dystocia Quality Improvement Finally, certain aspects of clinician style and healthcare systems may prevent labor dystocia and resultant cesarean section. These include caregiver continuity during the assessment of early labor,33 encouraging a “pronatalist” cultural attitude toward natural childbirth,81,82 requiring consultation with a second clinician prior to non-emergent cesarean deliveries for dystocia,81 and providing regular feedback to clinicians regarding their cesarean delivery rates.83 One small study also suggests a lower first-stage cesarean rate when a woman has her primary prenatal provider attending her in labor rather than an on-call hospitalist.84 Finally, improving quality of care as part of overall maternity safety has led to a plateauing of cesarean rates.85

In summary, labor dystocia is common and requires the maternity clinician to have excellent clinical assessment skills and thorough knowledge of both non-pharmacologic and pharmacologic strategies to prevent and treat non-progressing labor.

Labor Dystocia in Low Resource Settings Obstructed labor is the cause of eight percent of maternal deaths,86,1 primarily in developing countries. Management of obstructed labor in low-resource settings may be complicated by a number of factors including distance to health facilities, decreased availability of oxytocin and other medicines to induce and augment labor, lack of forceps and vacuum and inadequate access to safe cesarean. Use of a modified partogram is recommended by the World Health Organization (WHO) with alert and action lines to help determine when to intervene and when to transfer a patient if cesarean delivery is not a safe option locally. A 2012 Cochrane Review of six studies including 7,706 women found that using a partogram did not result in a significant decrease in cesarean or assisted vaginal delivery rate or APGAR scores less than seven at five minutes.87,2 Modified partograms in low- resource settings will need to be revisited, due to the recent literature summarized in this chapter, suggesting that active labor may not begin until approximately 6 cm.

Obstructed labor without access to safe cesarean delivery results in complications rarely seen in high- resource settings including maternal and fetal death and obstetric fistula (including communication between bladder, vagina and rectum). Obstetric fistula can lead to urinary and/or rectal incontinence that can have profound social and psychological in addition to physical consequences.

In settings without access to safe cesarean, symphysiotomy can expedite delivery avoiding some of the above complications. Additional details regarding labor dystocia in low-resource settings can be found in the Labor Dystocia Chapter Addendum of the Global ALSO Manual (www.aafp.org/globalalso). The Global ALSO Manual also has a chapter and workshop on symphysiotomy.

— Chapter F: Labor Dystocia — 11 SUMMARY TABLE OF RECOMMENDATIONS Strength of Recommendation A 1) Amniotomy should be reserved for slowly progressing labors as it reduces the risk of dysfunctional labor but is associated with variable fetal heart rate decelerations. Routine amniotomy is not recommended.17-19 2) Clinicians should support having women receive continuous labor support from a labor companion as the use of such a “doula” has been shown to help women use less analgesia, have lower rates of operative vaginal and cesarean delivery, and feel more satisfaction with their childbirth experiences.43 3) Clinicians should use epidural analgesia with care as epidurals are associated with a prolongation of the second stage of labor and an increase in oxytocin use and operative vaginal delivery, compared to opioids or no analgesia.64

Strength of Recommendation B 4) Active labor may not start until 6cm of dilation, so cesarean for dystocia should be avoided before this dilation.2 5) Quality improvement and patient safety strategies that monitor cesarean indications and rates can help lower these rates safely.5,85 6) Clinicians should allow slower labor progress in latent labor in women undergoing induction compared to spontaneous labor assuming fetal tolerance and no other compelling obstetric indication for intervention.2,63 7) Clinicians should allow slower labor progress throughout all stages of labor in obese women compared to non-obese women assuming fetal tolerance and no other compelling obstetric indication for intervention.2,41,42

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— Chapter F: Labor Dystocia — 13 35. Tuuli MG, Frey HA, Odibo AO, Macones GA, Cahill AG. 52. Vrouenraets FP, Roumen FJ, Dehing CJ, van den Akker ES, Immediate Compared With Delayed Pushing in the Second Aarts MJ, Scheve EJ. Bishop score and risk of cesarean Stage of Labor: A Systematic Review and Meta-Analysis. Obstet delivery after induction of labor in nulliparous women. Obstet Gynecol 2012;120:660–8. Gynecol 2005;105(4):690-697. 36. Ehrenberg HM MB, Catalano PM. The influence of obesity 53. Ehrenthal DB, Jiang X, Strobino DM. Labor induction and risk of and diabetes on the prevalence of macrosomia. Am J Obstet a cesarean delivery among nulliparous women at term. Obstet Gynecol 2004;191:964-968. Gynecol 2010;116:35–42. 37. Thangaratinam S, Rogozinska E, Jolly K et.al. Effects of 54. Jozwiak M, Bloemenkamp KWM, Kelly AJ, Mol BWJ, Irion interventions in pregnancy on maternal weight and obstetric O, Boulvain M. Mechanical methods for induction of labour. outcomes: meta-analysis of randomised evidence. BMJ. Cochrane Database of Systematic Reviews 2012, Issue 3. Art. 2012;344:e2088. No.: CD001233. DOI: 10.1002/14651858.CD001233.pub2. 38. Oteng-Ntim E, Varma R, Croker H, Poston L, Doyle P. Lifestyle 55. Hofmeyr GJ, Gülmezoglu AM, Pileggi C. Vaginal misoprostol for interventions for overweight and obese pregnant women to cervical ripening and induction of labour. Cochrane Database improve pregnancy outcome: systematic review and meta- of Systematic Reviews 2010, Issue 10. Art. No.: CD000941. DOI: analysis. BMC Med. 2012;10:47. 10.1002/14651858.CD000941.pub2. 39. Sanchez-Ramos L, Bernstein S, Kaunitz AM. Expectant manage- 56. Kelly AJ, Malik S, Smith L, Kavanagh J, Thomas J. Vaginal pros- ment versus labor induction for suspected fetal macrosomia: a taglandin (PGE2 and PGF2a) for induction of labour at term. systematic review.Obstet Gynecol. 2002;100(5 Pt 1):997-1002. Cochrane Database of Systematic Reviews 2009, Issue 4. Art. 40. Vahratian A, Zhang J, Troendle JF, Savitz DA, Siega-Riz AM. No.: CD003101. DOI: 10.1002/14651858.CD003101.pub2. Maternal prepregnancy overweight and obesity and the pat- 57. Alfirevic Z, Weeks A. Oral misoprostol for induction of labour. tern of labor progression in term nulliparous women. Obstet Cochrane Database of Systematic Reviews 2006, Issue 2. Art. Gynecol 2004;104(5 Pt 1):943-51. No.: CD001338. DOI: 10.1002/14651858.CD001338.pub2. 41. Norman SM, Tuuli MG,. Odibo AO, Caughey AB, Roehl KA, 58. Nicholson JM, Kellar LC, Cronholm PF, Macones GA. Active Cahill AG. The Effects of Obesity on the First Stage of Labor management of risk in pregnancy at term in an urban popula- Obstet Gynecol 2012;120:130–5. tion: an association between a higher induction of labor rate 42. Pevzner L, Powers BL, Rayburn WF, Rumney P, Wing DA. and a lower cesarean delivery rate.[see comment]. Am J Obstet Effects of Maternal Obesity on Duration and Outcomes of Gynecol 2004;191(5):1516-1528. Prostaglandin Cervical Ripening and Labor Induction. Obstet 59. Nicholson JM, Stenson MH, Kellar LC, Caughey AB, Macones Gynecol 2009;114:1315–21. GA. Active management of risk in nulliparous pregnancy at 43. Hodnett ED, Gates S, Hofmeyr GJ, Sakala C. Continuous term: association between a higher preventive labor induc- support for women during childbirth. Cochrane Database of tion rate and improved birth outcomes. Am J Obstet Gynecol Systematic Reviews 2013, Issue 7. Art. No.: CD003766. DOI: 2009;200:254.e1–13. 10.1002/14651858.CD003766.pub5. 60. Caughey AB. Preventive induction of labor: can its use lower 44. Campbell DA, Lake MF, Falk M, Backstrand JR. A randomized the cesarean delivery rate? J Womens Health 2009;18:1743–5. control trial of continuous support in labor by a lay doula.J 61. Klein, M. Association Not Causation: what is the intervention? Obstet Gynecol Neonatal Nurs. 2006;35(4):456-64. Ann Fam Med July 1, 2007,vol. 5 no. 4, 294-297. 45. See Doulas of North America, www.dona.org, accessed 62. Rouse DJ, Weiner SJ, Bloom SL, et al; Eunice Kennedy Shriver November 3, 2013. Also see Appendix 3. National Institute of Child Health and Human Development 46. Garite TJ, Weeks J, Peters-Phair K, Pattillo C, Brewster WR. A (NICHD) Maternal-Fetal Medicine Units Network (MFMU). Failed randomized controlled trial of the effect of increased intrave- labor induction:toward an objective diagnosis. Obstet Gynecol nous hydration on the course of labor in nulliparous women. 2011;117:267–72. Am J Obstet Gynecol 2000;183:1544–8. 63. Harper LM, Caughey AB, Odibo AO, Roehl KA, Zhao Q. Normal 47. Eslamian, Y, Marsoosi V, Pakneeyat Y. Increased intravenous progress of induced labor. Obstet Gynecol 2012;119:1113–8. fluid intake and the course of labor in nulliparous women. 64. Anim-Somuah M, Smyth RMD, Jones L. Epidural versus non- International Journal of Gynecology and Obstetrics 2006; epidural or no analgesia in labour. Cochrane Database of 93:102—105. Systematic Reviews 2011, Issue 12. Art. No.: CD000331. DOI: 48. Coco A, Derksen-Schrock A, Coco K, Raff T, Horst M, Hussar 10.1002/14651858.CD000331.pub3. E. A Randomized Trial of Increased Intravenous Hydration in 65. Lieberman E, Davidson K, Lee-Parritz A, Shearer E. Changes Labor When Oral Fluid Is Unrestricted. Fam Med 2010;42(1):52-6. in fetal position during labor and their association with epidural 49. ACOG Practice Bulletin Number 107: Induction of labor. analgesia. Obstet Gynecol. May 2005;105(5 Pt 1):974-982. American College of Obstetricians and Gynecologists. Obstet 66. Klein MC. Does epidural analgesia increase rate of cesarean Gynecol 2009;114:386–97. section? Can Fam Physician. Apr 2006;52:419-421, 426-418. 50. AAFP, Choosing Wisely, http://www.aafp.org/dam/AAFP/ 67. Wong CA, Scavone BM, Peaceman AM, et al. The risk of cesar- documents/journals/afp/choosing-wisely-table.pdf. Accessed ean delivery with neuraxial analgesia given early versus late in October 30, 2013. labor. N Engl J Med. 2005;352(7):655-665. 51. Vahratian A, Zhang J, Troendle JF, Sciscione AC, Hoffman MK. 68. ACOG committee opinion. No. 339: Analgesia and cesarean Labor progression and risk of cesarean delivery in electively delivery rates. Obstet Gynecol 2006;107(6):1487-1488. induced nulliparas. Obstet Gynecol 2005;105(4):698-704.

— Chapter F: Labor Dystocia — 14 69. ACOG Practice Bulletin. Number 36: Obstetric analgesia and 85. World Health Organization. Maternal mortality in 2005 : esti- anesthesia. Obstet Gynecol 2002;100(1):177-191. mates developed by WHO, UNICEF, UNFPA, and the World 70. Cluett ER, Burns E. Immersion in water in labour and birth. Bank; 2007. http://www.who.int/whosis/mme_2005.pdf Cochrane Database of Systematic Reviews 2009, Issue 2. Art. Accessed December 27, 2013 No.: CD000111. DOI: 10.1002/14651858.CD000111.pub3. 86. Lavender T, Hart A, Smyth R. Effect of partogram use on out- 71. Rooks, J. Safety and risks of nitrous oxide labor analgesia: a comes for women in spontaneous labour at term. Cochrane review. J Midwifery Womens Health. 2011 Nov-Dec;56(6):557-65. Database Syst Rev. 2012. 72. Collins MR, Starr SA, Bishop JT, Baysinger CL. Nitrous oxide for labor analgesia: expanding analgesic options for women in the United States. Rev Obstet Gynecol 2012;5(3-4):e126-31. 73. Hutton E, Kasperink M, Rutten M, Reitsma A, Wainman B. Sterile water injection for labour pain: a systematic review and metaanalysis of randomised controlled trials. BJOG 2009;116:1158–1166. 74. Derry S, Straube S, Moore RA, Hancock H, Collins SL. Intracutaneous or subcutaneous sterile water injection com- paredwith blinded controls for pain management in labour. Cochrane Database of Systematic Reviews 2012, Issue 1. Art. No.: CD009107. DOI: 10.1002/14651858.CD009107.pub2. 75. Mark SP, Croughan-Minihane MS, Kilpatrick SJ. Chorioamnionitis and uterine function. Obstet Gynecol 2000;95(6 Pt 1):909-912. 76. Seaward, P. et.al. International Multicentre Term Prelabor Rupture of Membranes Study: Evaluation of predictors of clinical chorioamnionitis and postpartum fever in patients with prelabor rupture of membranes at term. Am J Ob Gyn 1997: 177(5): 1024-1029. 77. Cahill AG, Duffy CR, Odibo AO, Roehl KA, Zhao Q, Macones GA. Number of cervical examinations and risk of intrapartum maternal fever. Obstet Gynecol .2012;119(6):1096-101. 78. Lupe PJ, Gross TL. Maternal upright posture and mobility in labor--a review. Obstet Gynecol 1986;67(5):727-734. 78. Bloom SL, McIntire DD, Kelly MA, et al. Lack of effect of walking on labor and delivery. N Engl J Med. 1998;339(2):76-79. 79. Albers, L. The Evidence for Physiologic Management of the Active Phase of the First Stage of Labor. J Midwifery Womens Health 2007;52:207–215. 80. Leeman L, Leeman R. A Native American community with a 7% cesarean delivery rate: does case mix, ethnicity, or labor management explain the low rate? Ann Fam Med. 2003;1(1):36-43. 81. Deline J, Varnes-Epstein L, Dresang LT, Gideonsen M, Lynch L, Frey JJ. . Low Primary Cesarean Rate and High VBAC Rate With Good Outcomes in an Amish Birthing CenterAnn Fam Med 2012;10:530-537. 82. Khunpradit S, Tavender E, Lumbiganon P, Laopaiboon M, Wasiak J, Gruen RL. Non-clinical interventions for reducing unnecessary caesarean section. Cochrane Database Syst Rev 6:CD005528, 2011. 83. Abenhaim HA, Benjamin A,. Koby RD, Kinch RA, Kramer MS. Comparison of obstetric outcomes between on-call and patients’ own obstetricians. Cmaj 2007;177:352-356. 84. Clark SL, Belfort MA, Byrum SL, Meyers JA, Perlin JB. . Improved outcomes, fewer cesarean deliveries and reduced litigation: results of a new paradigmin patient safety. Am J Obstet Gynecol 2008;199:105.e1-7.

15 — — Chapter F: Labor Dystocia APPENDIX 1

Sample Labor Orders for Oxytocin Augmentation 1. Consider oxytocin augmentation if: a) Cervical dilation rate is less than 0.3 to 0.4 cm per hour for a woman up to 5 cm dilation or < 0.7 cm per hour if over 8 cm dilation b) Contractions occur less frequently than every three minutes c) Contractions last less than 30 seconds d) Contractions are not palpable e) Intrauterine pressure catheter documents less than 200 Montevideo units (MVU) in a 10 minute period f) Amniotomy does not cause labor progress in one to three hours 2. Document the decision to augment in the medical record. 3. Electronically monitor fetal heart rate and uterine activity a minimum of 30 minutes prior to initiation of oxytocin. 4. Measure blood pressure every 15 to 30 minutes. 5. Start primary intravenous infusion of 1000 cc Lactated Ringers solution at a “keep vein open” rate. 6. Add, through the infusion pump, a secondary IV of 1000 cc D5/LR solution with 10 to 20 units of pitocin (20 units preferred to decrease the total amount of fluid administered). 7. Begin oxytocin infusion at 0.5 to 2 mU/minute. 8. Increase oxytocin by 1 to 2 mU/minute every 30 minutes, until an adequate contraction pattern has been reached. After 10 mU/minute has been reached the rate of increase may be 1 to 4 mU/minute. 9. Notify provider before exceeding 20 mlU/minute. The provider should document in the medical record any decision to exceed this dosage. The maximum infusion rate is 36 mU/minute 10. Stop or decrease oxytocin by 50% if any of the following occur: a) Tachysystole (more than 5 contractions within 10 minutes averaged over 30 minutes). b) Uterine tone between contractions exceeds 15 to 20 mm Hg. c) Tetanic contractions occur (contractions lasting over two minutes in length). d) Severe variable, late decelerations, bradycardia or tachycardia occur. e) Less severe patterns may be managed as if the patient were in spontaneous labor, by administration of a fluid bolus, position change, and oxygen at 6 L/min. f) Interventions such as these should be documented in the medical record. 11. Consider augmentation to have failed if a) the woman is at least 6 cm dilated with ruptured membranes and has had no cervical change with four hours of adequate contractions (defined as > 200 Montevideo units in 10 minutes) by intrauterine pressure catheter or six hours of inadequate contractions, or b) no regular contractions (every three minutes) after 24 hours of oxytocin, preferably with rupture of membranes.

— Chapter F: Labor Dystocia — 16 APPENDIX 2

Intradermal Sterile Water Injections The use of intradermal sterile water injections can be used to treat first-stage “back labor.” Four 0.1 ml intradermal injections of sterile water with a 25 gauge or 27 gauge needle are given to form small blebs in the skin. Two injection sites are over the posterior superior iliac spines; two are 2 to 3 cm below and 1 to 2 cm medial to the first points. The injections cause intense stinging for 15 to 30 seconds, followed within two minutes by partial to complete relief of back pain lasting 45 to 90 minutes. These injections can be repeated if necessary. Using two clinicians, these injections can be easily injected simultaneously to decrease the duration of discomfort.

From The nature and management of labor pain: part I. Nonpharmacologic pain relief.Leeman L, Fontaine P, King V, Klein MC, Ratcliffe S.Am Fam Physician. 2003 Sep 15;68(6):1109-12.

17 — — Chapter F: Labor Dystocia APPENDIX 3

Various Doula Organizations This list is not meant to be complete but to provide a resource. Most of the doula certification programs require that a trainee provide labor support for a certain number of births in order to obtain certification.

Doulas of North America International — DONA, http://www.dona.org

Childbirth and Postpartum Professional Association — CAPPA, http://www.cappa.net

Association of Childbirth Educators and Labor Assistants — ALACE, http://www.alace.org

International Childbirth Education Association — ICEA, www.icea.org

Operation Special Delivery — http://www.operationspecialdelivery.com

• This organization offers free doula services during wartime to pregnant women with partners on deployment in the U.S. military.

http://www.doulas.com/collects doula resources

18 — — Chapter F: Labor Dystocia Chapter G Malpresentations, Malpositions, and Multiple Gestation slide 1 Steven H. Eisinger, MD Published 2000

OBJECTIVES slide 2 After completing this chapter, participants will be able to: 1. Define six types of malpresentations and methods for diagnosis. 2. List complications associated with each malpresentation. 3. Discuss the criteria for allowing vaginal delivery, and the management of vaginal delivery, when appropriate. 4. Discuss multiple gestation, with special attention to labor and delivery. 5. Perform safe, effective delivery of various malpositions and malpresentations using the maternal-fetal mannequin. slide 3 DEFINITIONS Definitions are important to a discussion of malpresentations. Lie refers to the relationship of the long axis of the fetus to that of the mother, specified as longitudinal, transverse, or oblique (also referred to as unstable). Presentation refers to the portion of the fetus that is foremost or “presenting” in the birth canal. The fetus may present by its vertex, breech, face, brow, or shoulder. Position refers to a reference point on the presenting part, and how it relates to the maternal pelvis. For example, the reference point on the vertex is the occiput. When the fetal occiput is directed toward the mother’s symphysis, or anteriorly, the fetus is in occiput anterior (OA) position. When the occiput is directed toward the maternal spine, the fetus is occiput posterior (OP). Intermediate positions around the compass are left and right occiput anterior (LOA and ROA), left and right occiput transverse (LOT and ROT), and left and right occiput posterior (LOP and ROP).

METHODS OF DIAGNOSIS slide 4 There are three principal methods of determining fetal lie, presentation, and position. The first is Leopold’s maneuvers or abdominal palpation. The second method is vaginal exam. The third method is imaging. Ultrasound is the preferred imaging method. Labor floor ultrasound examination is widely utilized in hospitals of all sizes, and every birth provider should have acquaintance with ultrasound skills in this setting to determine fetal lie, presentation, and position. Occasionally x-ray is necessary, particularly when fine detail is needed, such as the position of the limbs in a breech.

— Chapter G: Malpresentations, Malpositions, and Multiple Gestation — 1 Incidence of Malpresentations at Term1,2

Malpresentation Incidence Percent

Occiput posterior 1 in 10 to 20 5 to 10 Breech 1 in 25 to 33 3 to 4 Transverse lie or shoulder presentation 1 in 322 to 420 0.3 to 0.23 Face 1 in 500 to 1200 0.2 to 0.08 Compound presentation 1 in 700 to 2235 0.14 to 0.047 Brow 1 in 4470 0.02

THE FETAL HEAD AND THE MATERNAL PELVIS Most fetal malpresentations (posterior, breech, face, brow) are clinically significant because the slide 5 fetal head is not round, but rather ovoid or egg-shaped. The smallest of the fetal diameters is the suboccipitobregmatic; the largest is the occipitomental. The difference between them is three centimeters, or about 24 percent. When the head is in full flexion, the suboccipitobregmatic or smallest diameter presents to the pelvis. When the head is in full extension (or deflexion) the occipitomental or largest diameter presents. Delivery is much more likely to occur, and will be easier, if a smaller diameter presents. Therefore, the attitude of the fetal head (flexion versus extension) as it presents to the pelvis is of paramount importance. A degree of fetal extension of the head occurs with OP presentations, face and brow presentations, and some breeches.

Asynclitism also plays a major role in the mechanics of labor. Asynclitism is lateral flexion of the head, slide 6 such that the sagittal suture is not in the middle of the birth canal. Some degree of asynclitism is normal, and the fetal head may even shift back and forth from anterior to posterior asynclitism as the head accommodates more deeply into the pelvis. Extreme degrees of asynclitism may prevent labor from progressing. Asynclitism becomes a major factor in adequate forceps application.

The maternal pelvis also plays an important role in the cause of various malpresentations and slide 7 prognosis for delivery. There are four pure types of pelves. Most women have a gynecoid or intermediate type: • Gynecoid (round) • Anthropoid (oval, with the long axis in the AP plane) • Platypelloid (oval, with the long axis in the transverse plane) • Android (triangular or heart-shaped, with the apex of the triangle anteriorly)

While a full discussion of pelvic types and pelvimetry is of limited clinical usefulness, it can be generalized that a narrow pelvis such as the anthropoid can cause persistent occiput posterior; the platypelloid pelvis can cause a transverse arrest; the android pelvis is prejudicial to delivery with all malpresentations; and an inadequate or small pelvis can be associated with most of the malpresentations, mainly based on the inability of the head to descend, engage, or rotate.

2 — — Chapter G: Malpresentations, Malpositions, and Multiple Gestation OCCIPUT POSTERIOR POSITION In the Occiput Posterior (OP) position, the fetus lies with its occiput towards the mother’s spine and its face towards the mother’s symphysis and abdomen. In other words, the fetus is face up when the mother is supine or in lithotomy position. Usually the fetus in occiput posterior position will rotate spontaneously to occiput anterior (OA) and deliver spontaneously. Spontaneous rotation fails to occur in five to ten percent of cases, and the fetus remains in persistent occiput posterior position. The exact cause of persistent OP is unknown, but transverse narrowing of the pelvis plays a role. All occiput posterior fetuses are somewhat deflexed because the vertex drops back to fill the hollow of the sacrum. The combination of deflexion and posterior presentation causes less favorable diameters of the fetal head to present to the pelvis than when the fetus is in the occiput anterior position.

slide 8 The diagnosis of OP is based on observation of the patient and examination. Ultrasound imaging can be helpful but is sometimes confusing. Easy palpation of the anterior fontanel on vaginal exam is a diagnostic aid in determining OP position. This is true because the anterior fontanel is most easily felt when the head is somewhat deflexed. If the anterior fontanel is palpated, then one must identify the sagittal suture. This can be accomplished by following each suture with the examining finger until the posterior fontanel is encountered. Occasionally an ear can be palpated, revealing the fetal position. The exam can be confusing due to molding, overriding of sutures, edema, and asynclitism. Dilation is often asymmetric and a persistent anterior lip is common. Back pain, or “back labor,” is a clinical hallmark of OP position.

The diagnosis of OP can be very difficult. Most obstetric care providers have had the experience of making the diagnosis at the last minute when the fetal head seems to fill the posterior pelvis as it delivers, or even later as the fetal face becomes visible under the symphysis. In the “old days” even skilled operators occasionally rotated babies “the wrong way,” from OA to OP, to the delight of their residents!

slide 9 The conduct of labor and delivery with a persistent OP is not markedly different from that of the fetus in the occiput anterior position.1 (Category C) The progress of labor can be followed by cervical dilation and the descent of the vertex through the birth canal. Labor with OP position is prolonged on the average for one hour in parous women, and two hours in nulliparous women. Perinatal mortality does not differ significantly from OA, and there is no significant difference in Apgar scores. However, perineal lacerations and extensions of episiotomies may be increased because the vertex sweeps through the posterior pelvis, larger diameters are presented to the pelvic outlet, and the occiput places maximal pressure on the perineum as it delivers. There are five possibilities for vaginal delivery when persistent occiput posterior occurs: 1. Spontaneous Delivery — Spontaneous delivery occurs 45 percent of the time in one study utilizing expectant management.3 Because the fetal head cannot stem upward until the face has cleared the symphysis, the fetal vertex must pass through the posterior pelvis, where it places strain on the perineum. These babies look like they “want” to deliver through the rectum. However, frequently the delivery is easy. 2. Manual Rotation — Midwives and labor and delivery nurses have long held that fetuses in OP slide 10 position can be turned by placing the laboring woman in various positions such as on her side, squatting or ambulating, on hands and knees, or with her back arched (to make the fetus uncomfortable, so it turns itself!). Failing these maneuvers, manual rotation becomes an attractive alternative during a long second stage of labor because it can be attempted during any vaginal exam. If successful, delivery may be greatly expedited; if unsuccessful, no harm has been done.

— Chapter G: Malpresentations, Malpositions, and Multiple Gestation — 3 The key to manual rotation is to enhance the natural and normal forces of rotation. Rotation normally occurs when the flexed fetal head strikes the muscles of the pelvic floor, known as the levator sling. The operator must first therefore flex the fetal head. This is accomplished by placing a hand in the posterior pelvis behind the occiput. The operator’s hand essentially replicates and enhances the levator sling effect, acting like a wedge to flex the head. Then rotatory force is applied to the head, using for purchase any fontanel or suture that may be felt with the examining fingers. Some operators grasp the head with the thumb as well. The rotation should be attempted at the same time as a contraction, and with the mother pushing as well, to force the head down on the levator sling (and the hand), which is the natural mechanism for flexion and rotation. An experienced assistant may massage the fetal shoulder in the direction of the rotation with suprapubic or abdominal pressure. Manual rotation may be attempted with the patient in lithotomy position, or lateral Sims’ position, or on hands and knees. In the hands and knees position the abdominal assist is impractical. A commonly encountered question relates to which hand should be used to rotate the fetus. If the fetus were straight OP, the operator would naturally use his/her dominant hand. But, if the fetus were already rotated somewhat, either in the ROP or LOP position, then rotation should go “the shortest distance”. Therefore, an ROP should be rotated clockwise, and a LOP should be rotated counterclockwise. The hand should be used which pronates during the rotation (like closing a book): left hand for ROP and right hand for LOP.4 (Category C) Manual rotation is part of the “gentle art” of obstetrics. It is a neglected skill, but one which requires no technology or instrumentation. Risk is minimal. With practice, confidence and skill improve. Successful manual rotation may shorten the second stage of labor and avoid instrumentation, or even a cesarean delivery. 3. — Vacuum delivery is an attractive option in persistent OP presentation. The Vacuum Delivery slide 11 vacuum cup may safely be applied even when the operator is not completely confident of the exact position of the head, due to molding, edema, and overriding of sutures. The vacuum may successfully draw the head out in the OP position. Alternatively, in flexing the head and drawing it down against the levator sling, the vacuum may promote rotation. Delivery will then occur in the OA position. The vacuum allows the fetal head to find its own best plane for delivery. Many operators have been startled to see the head rotate 180 degrees as they tract, sometimes in the very moment before delivery. The vacuum cup should be placed as far posteriorly on the head as possible to promote flexion. (See Chapter H. Assisted Vaginal Delivery) No direct rotary force should be applied to the cup, as this may cause “cookie cutter” type injury to the scalp, and also may cause the cup to dis- engage. The mechanism of delivery for an OP is the same with a vacuum as with forceps or a spontaneous delivery: the fetal vertex takes a more posterior course through the pelvis. As with any vacuum delivery, the shaft of the extractor must be kept at right angles to the plane of the cup, or detachment will occur. 4. Forceps Delivery — The usual indications for forceps delivery apply. Forceps fit the occiput slide 12 posterior vertex equally as well as the occiput anterior vertex. The mere presence of an OP presentation is not in itself a sufficient indication for forceps use. The mechanism of delivery is the same as for a spontaneous OP delivery. The head is actually born by flexion, not extension. The fetal face must pass beneath the symphysis before the head can flex upward, so traction on the forceps must be in a more posterior direction for longer than with OA deliveries. Pressure on the perineum can be intense with resulting third and fourth degree lacerations.

4 — — Chapter G: Malpresentations, Malpositions, and Multiple Gestation Occasionally, with an occiput posterior and a prolonged second stage, severe molding and edema will occur. Then the fetal vertex will present in the midpelvis or even on the perineum, but careful exam will reveal that the fetal head is very elongated and the biparietal diameter is not even engaged. Under such circumstances attempts at operative delivery are not likely to be successful, and may even be hazardous. Cesarean delivery is indicated, at which time the lack of engagement may be confirmed by the ease with which the fetus is lifted out of the pelvis. 5. Forceps Rotation — Only skilled operators trained in the Scanzoni or Kielland techniques should consider forceps rotation. In most American hospitals, these techniques are seldom practiced now. Cesarean delivery should always be the backup method of delivery for any OP presentation that cannot be safely delivered vaginally.

BREECH PRESENTATION Breech presentation is defined as the fetal breech or buttocks presenting in the birth canal, with slide 13 the head aftercoming in the uterine fundus. Breech presentations may be classified as follows: • Frank breech: hips flexed and legs extended over the anterior surface of the body, occurring in 45 to 50 percent of breeches. • Complete breech: (also called Full): hips and legs flexed (tailor sitting or squatting), occurring in 10 to 15 percent of breeches. • Footling breech: one or both hips and knees extended with one or both feet presenting, occurring in 35 to 45 percent of breeches. slide 14 Breech presentation has many predisposing factors. Prematurity is commonly associated with breech, and as the fetus approaches term the incidence of breech drops to three to four percent.

Fetal Presentation at Various Gestational Ages Modified from Scheer and Nubar5

Gestation (weeks) Percent breech

21 to 24 33 percent 25 to 28 28 percent 29 to 32 14 percent 33 to 36 9 percent 37 to 40 7 percent

Other predisposing factors include high parity and relaxation of the uterine and abdominal wall; uterine anomalies; pelvic tumors; polyhydramnios; oligohydramnios; various fetal anomalies including hydrocephalus, anencephaly, and Down Syndrome; macrosomia; multiple pregnancy; placenta previa; absolute cephalopelvic disproportion; and previous breech. Because of these associated factors, a formal ultrasound with a fetal anatomical survey is indicated when the diagnosis of breech is made in the mid-third trimester or later. Often, no cause is found.

— Chapter G: Malpresentations, Malpositions, and Multiple Gestation — 5 Diagnosis The diagnosis of breech can often be made by abdominal palpation and vaginal exam. On Leopold’s maneuvers, the firm, ballotable, rounded head is felt in the fundus.

On vaginal exam, either small parts or the breech itself may be detected. If small parts are palpated, it is essential to distinguish between a hand and a foot.

The breech itself is smooth and rounded, and may feel remarkably like a vertex. Most childbirth providers have had the experience of “missing a breech” on vaginal exam. The key is to seek fonta- nels and sutures with the examining finger, which always signify a vertex. In breech presentation, the anus and ischial tuberosities form a straight line, whereas the mouth and malar prominences form a triangle. Additionally, the skin of the fetal buttock is smooth. An alert examiner can distinguish it from the hairy feel of the scalp. This subtle sign may raise an examiner’s index of suspicion to perform a more definitive exam. If the examiner’s finger encounters an orifice, then the finger can be gently inserted into the orifice. If it is the mouth, (signifying a face presentation) the fetus will suck on the finger. If it is the anus (signifying a breech), the finger will be coated with meconium when withdrawn.

Prenatal Management of Breech There are four elements to the prenatal management of breech. First, a cause must be sought for the breech presentation. Most of the causes of breech presentation that can be identified are detect- slide 15 able by ultrasound. Secondly, the patient may attempt certain exercises to turn the breech. Thirdly, external cephalic version may be contemplated and attempted. Fourthly, failing successful version, a decision must be reached regarding the most favorable mode of delivery.

Postural Management of Breech Presentation Various exercises and positions have been tried in an attempt to turn a breech. No difference in outcome has been noted in a review of trials in which women were randomized to either a postural slide 16 management group or a control group.6,7 (Category C)

The exercises themselves are simple. One version of the exercises is for the woman to assume a knee-chest position for 15 minutes three times a day, for five days after the diagnosis of the breech. Another version is for the woman to assume a deep Trendelenburg position by elevating her hips nine to twelve inches while lying supine, for ten minutes once or twice a day. Pelvic rocking while in either of these positions is often recommended.

While efficacy cannot be proven, these exercises do no harm, and they do provide a focus of activity for an anxious gravida (and maternity care provider!). There are no contraindications to doing these exercises.

External Cephalic Version (ECV) External cephalic version, or turning a breech fetus to vertex by manipulation through the mother’s abdominal wall and uterus, has become an accepted component of the prenatal management of breech presentation. Williams Obstetrics (20th Edition), the Cochrane Data Base, and ACOG Practice Bulletin (Feb. 2000 #13) all support ECV for breech presentations.8,9,10 This procedure is low tech and low cost, can lower cesarean delivery rates, saving these women from potential operative morbidity. The risk of an adverse event occurring as a result of ECV is small, and the cesarean

6 — — Chapter G: Malpresentations, Malpositions, and Multiple Gestation delivery rate is significantly lower among women who have undergone successful version. Women near term with breech presentations should be offered a version attempt.9,10 (Category A)

The success rate of ECV, averaged from many studies, is 58 percent. In a comprehensive program of ECV, cesarean delivery for breech can be reduced by half. Factors associated with success of slide 17 ECV are: parity, frank breech presentation, normal or increased amniotic fluid, and a relaxed uterus. Negatively associated with success are: nulliparity, obesity, oligohydramnios, anterior placenta, and low station of the breech. The operator’s skill and the patient’s tolerance of the procedure also play a large role in success. Gestational age is also a factor in the success rate. Prior to 37 weeks, the initial success is good, but reversion is common. Furthermore, if expedited delivery becomes necessary, the fetus is premature. ECV after 37 weeks has a significantly lower success rate. This gestational age appears to be optimal for ECV, as the success rate is still good, the reversion rate back to breech is low, and, should immediate delivery be necessary, the fetus is sufficiently mature.9,10 (Category A) ECV in early labor is difficult, although some success has been reported.

Several contraindications to ECV exist: multiple pregnancy (although ECV is a good potential slide 18 management strategy for a breech second twin), poor fetal heart rate tracing, utero-placental insufficiency, uterine anomalies, placenta previa or unexplained bleeding, and maternal medical conditions such as cardiac disease or pregnancy-induced hypertension. One small, randomized study examined ECV in patients with previous cesarean delivery; success was good and uterine rupture did not occur.11

Various strategies have been employed to increase the success of ECV. Routine tocolysis appears to reduce the failure rate of external cephalic version at term. Although promising, there is not enough evidence to evaluate the use of fetal acoustic stimulation in midline fetal spine positions.12 There is not enough evidence to evaluate the use of epidural analgesia or transabdominal amnioinfusion for external cephalic version at term.12 slide 19 Complications of ECV are infrequent. Fetal bradycardia and decelerations are common, noted in 40 percent of cases, but usually resolve spontaneously or with cessation of the procedure. Sporadic reports have been noted of abruption, fetal hemorrhage, maternal hemorrhage, knotted or entangled cord, fetal mortality, and maternal mortality due to amniotic fluid embolism. A 1993 report noted no fetal deaths since 1980.13 When performing ECV, facilities and personnel must be available for performing an immediate cesarean delivery.13 (Category C)

— Chapter G: Malpresentations, Malpositions, and Multiple Gestation — 7 Procedure for External Cephalic Version (This is a sample protocol similar to many published protocols. Other variations exist.) Preparation • Patient may be accompanied by support person • Patient NPO (nothing by mouth) • Patient gowned, bladder empty • Confirm breech by ultrasound and rule out fetal anomalies • Perform NST (nonstress test) or BPP (biophysical profile) • Obtain consent • Cesarean delivery personnel and facilities available • Intravenous access • Tocolysis (recommended for primagravidas; optional for multiparas): 0.25 mg of terbutaline (subcutaneous) 15 minutes before starting the procedure, or any approved tocolytic regimen • Position: supine, slight left lateral tilt, Trendelenburg, knees slightly bent • Abdomen coated with ultrasound gel

Procedure (for two operators) slide 20 • Operator #1 elevates breech from pelvis by driving a hand suprapubically beneath the breech. • Operator #1 pushes the breech into the iliac fossa. slide 21 • Operator #2 flexes the head (for a forward roll), and rotates the fetus into an oblique lie. • Two thirds of the force or pressure should be applied to the breech, and one third of the force should be applied to the head. Avoid excessive force. Use a massaging motion when possible rather than direct steady pressure. • Both operators should rotate the fetus slowly around. Just enough force or pressure should be used that moves the fetus. Progress will occur in stages, or “cogwheel” fashion. The fetus will rotate slightly, then resist, then rotate more. Allow the mother and fetus brief rest periods when resistance is felt, while attempting to maintain the progress already achieved. • Monitoring may be by ultrasound or doppler, and should be performed every 30 seconds, slide 22 during rest periods. • When the fetus is just past the transverse, it may rotate the rest of the way without effort, as it accommodates to the shape of the uterus slide 23 • The vertex may be guided gently over and into the pelvic inlet with suprapubic manipulation and fundal pressure. • Ultrasound to confirm success. slide 24 • After successful version, monitor for 20 to 30 minutes or until a reactive pattern occurs. • If the ECV is very easy, or if it is a second ECV after a fetus has reverted to breech, then a binder may be placed on the abdomen to hold the fetus in place, and induction initiated. • In Rh negative patients, administer D-immune globulin (Rhogam®); may obtain Kleihauer-Betke test. • If the forward roll fails, then try a backward flip, especially if the vertex and breech lie on the same side of the maternal midline. • This procedure can be strenuous for the operators. A third operator can relieve the other two at intervals. • If no success by 15 to 20 minutes, then discontinue the procedure. • If the patient feels sharp pain, stop the procedure. • If bradycardia occurs, stop the procedure. If it persists, then revert the fetus to its original breech position. If the bradycardia still persists, then prepare for cesarean delivery.

8 — — Chapter G: Malpresentations, Malpositions, and Multiple Gestation Choosing Route of Delivery for Breech The optimal route of delivery for breech infants has been the subject of much controversy. Currently, in the United States, most breeches (well over 90 percent in some institutions and nearly all primagravidas) are delivered by cesarean delivery. However, rigorous support for this practice has been lacking in the literature. Numerous studies have shown the safety of vaginal delivery for selected breeches. Additionally, cesarean delivery does not prevent all infant morbidity, which, in some cases, arises from the same problems that caused the breech presentation in the first place.14 A Cochrane review suggests that adequate evidence does not exist to evaluate the use of a policy of planned cesarean section for breech presentation.15 However, a multi-center, international, randomized controlled trial compared elective cesarean delivery to vaginal delivery for selected breech presentations: greater than 37 weeks, frank or complete breech, and less than 4000 grams estimated fetal weight.17,18 This trial was terminated early, in April 2000, after preliminary data analysis showed significant reduction in perinatal mortality and morbidity, and no increase in serious maternal complications, in the elective cesarean group.17

Two considerations, not strictly medical, enter into the decision regarding cesarean versus vaginal delivery. First, the skills to perform a safe vaginal breech delivery are not being taught in many residencies, and practitioners who retain these skills are aging. Second, the medical-legal ramifica- tions of vaginal delivery are prohibitive in the minds of many. slide 25 Certain contraindications exist for elective vaginal delivery of breech infants: • Unfavorable pelvis: if the pelvis is known to be small, or if it is android or platypelloid, vaginal delivery should not be attempted. X-ray or CT pelvimetry have not been shown to improve outcomes for breech births. • Macrosomia (defined variously, from 3800 grams upward). • Severe prematurity (defined variously). • Intrauterine growth restriction or evidence of placental insufficiency. • Footling breech. • Hyperextension of the fetal head: delivery can be difficult, and labor can result in neurological injuries with a hyperextended head. An X-ray of the abdomen may be necessary to determine the attitude of the fetal head. • Fetal anomalies such as hydrocephalus. • Nuchal arm: again an x-ray is required to diagnose this condition. • Absence of labor, as in premature rupture of membranes, or non-progressive labor: induction and augmentation of labor are controversial in the literature, but often avoided in favor of cesarean delivery. • Lack of a physician with the experience and skill necessary for vaginal delivery.

Various scoring systems have been developed to predict outcome of vaginal breech delivery. The best known of these systems is the Zatuchni-Andros Prognostic Scoring Index. It awards points for parity, gestational age less than 37 weeks, estimated fetal weight less than seven pounds, previous breech delivery, dilation at presentation, and station at presentation.16 This system has several faults, among them rewarding prematurity, and also rewarding the gravida who stays home to labor, thus presenting at a greater dilation and lower station. However, no better-validated system of predicting breech outcome has been developed.

— Chapter G: Malpresentations, Malpositions, and Multiple Gestation — 9 In summary, the decision as to the best mode of delivery of a breech is complicated. Many factors must be taken into account, including the best conclusions from the medical literature, community and national standards, the specifics of each individual case, the patient’s wishes, and the skill of the operator.

LABOR AND DELIVERY Presented here is a standard method of delivering a breech per vagina. Variations of this method exist. ALSO offers this technique as not necessarily the only one, nor even the best, but one which is widely accepted by American practitioners and which can be learned and practiced on the mannequin. ALSO acknowledges that vaginal breech deliveries do occur, sometimes emergently under circumstances in which cesarean delivery or consultation are not possible. Therefore, every obstetric provider should have a working knowledge of how to deliver a breech.

There are fundamental differences in delivery between cephalic and breech presentations. With slide 26 cephalic or vertex presentation, the largest part of the fetus, the head, delivers first. Molding of the cranium can occur over several hours. With a breech delivery, first the breech, then the shoulders, then the head delivers, each larger and less compressible than the previous part. Molding of the head has no opportunity to occur because the fetal head is in the pelvis only for a few minutes, and because it enters the pelvis with the base of the skull leading, which, unlike the vertex, cannot mold. The great challenge of the vaginal breech delivery is that the last part of the fetus to deliver is also the largest part, and it might not fit through the pelvis.

Labor with a breech is not very different from labor with a vertex, and may be allowed to continue spontaneously as long as progressive dilation and descent occur, and there is no fetal or maternal compromise.

A frank breech will distend the perineum and dilate the introitus in a manner similar to a vertex. Episiotomy is often recommended. While episiotomy will not create more room in the bony pelvis, it will enable the operator to perform various manipulations more easily, including emergency procedures such as Piper forceps application. Episiotomy is very difficult to perform once the whole body is out.

The frank breech usually delivers with the axis of the hips in the AP plane, and the fetal sacrum will slide 27 either be to the left or the right. Usually, the anterior hip descends to the introitus and passes below the symphysis in a manner analogous to the anterior shoulder. Then with lateral flexion of the fetal body, the posterior hip delivers over the perineum. The operator may support the perineum with a Ritgen-type maneuver, or the breech may be allowed to deliver spontaneously. External rotation follows delivery of the breech, allowing the infant’s back to turn anteriorly.

Delivery should proceed spontaneously until the fetal umbilicus appears at the introitus. The mother should be making strong, but controlled, pushing efforts at this point in the delivery. Traction by the operator prior to delivery of the umbilicus may promote extension of the fetal head or nuchal placement of the arms. Do not pull on the fetus until the umbilicus is delivered, and, even then, traction is not necessary if the delivery continues to progress.

10 — — Chapter G: Malpresentations, Malpositions, and Multiple Gestation When the umbilicus delivers, a loop of several inches of cord should be gently pulled down. This prevents tension on the cord as the body delivers, and also allows easy monitoring of the fetal pulse by palpation. slide 28 The legs of a frank breech may be delivered by inserting a finger behind the knee to flex the knee and abduct the thigh. Active efforts to deliver the legs are not mandatory, as the legs will deliver spontaneously and the feet will “spring” free eventually. Delivery of the legs in this manner can be accomplished, before the breech has delivered, by a skilled practitioner who is attempting a total breech extraction. slide 29 After the umbilicus is born, gentle downward traction may be used to deliver the infant’s torso. The fetus may be grasped by the operator’s fingers on the fetal pelvis, with thumbs on the sacroiliac regions. This avoids placing the hands too high on the fetus and injuring abdominal organs such as the spleen or liver. Traction should be in a 45-degree downward axis, toward the floor. It is helpful for the operator to assume a position below the fetus, as for example on one knee in front of a delivery room table.

The fetal trunk may deliver quickly and without operator effort, or considerable effort may be required to deliver the trunk. Rotation of the fetal back from one anterior oblique to the other anterior oblique may be helpful in extracting the trunk, and it also encourages the fetal arms to gather in a flexed position across the chest. This rotatory maneuver carries an eponym in Great Britain, where it is called the Lovsett maneuver. Of critical importance is keeping the back up during the delivery, which allows the fetal head to enter the pelvis occiput anterior. If the fetus rotates abdomen up, the fetal head will present very unfavorable diameters to the maternal pelvis, severely jeopardizing safe delivery. slide 30 Delivery of the arms is accomplished by rotating the fetal body into the oblique. The tip of the fetal scapula will come into view, usually quite easy to identify because it is “winged.” The anterior arm may then be swept down across the fetal chest and out of the introitus. If possible, the humerus should be splinted with two fingers rather than simply hooking the antecubital fossa with a finger. Rotation of the fetus into the opposite oblique allows delivery of the opposite arm in a similar fashion.

Delivery of the head follows, and is potentially the most difficult and hazardous part of the breech delivery. The head must be born by flexion through the pelvis. When the breech head is flexed and occiput anterior, and then passes through the birth canal by further flexion, the same favorable diameters are presented to the pelvis as in the case of a vertex occiput anterior delivery.

A modification of the Mauriceau Smellie Veit (MSV) maneuver is recommended to deliver the head slide 31 by flexion. Everything about the MSV maneuver is designed to promote flexion. One of the operator’s hands should be placed above the fetus with one finger inserted into the vagina and placed on the occiput, and one finger on each of the fetal shoulders. The other hand is placed beneath the fetus. The classical MSV maneuver describes placing a finger in the mouth, but this is not recommended because traction on the jaw can cause dislocation. As an alternative, two fingers may be placed on the maxillae. A very competent assistant should follow the head abdominally, and be prepared to apply suprapubic pressure to flex the head through the pelvis. The fetus may be wrapped in a sling that is also held by an assistant, or may be draped on the operator’s lower arm.

— Chapter G: Malpresentations, Malpositions, and Multiple Gestation — 11 Delivery of the head then commences. The head is flexed through the pelvis by four separate mechanisms: the occipital finger applies flexing pressure on the occiput; the assistant applies suprapubic pressure on the occiput as well; the fingers on the maxillae apply pressure on the lower face, which tends to promote flexion. The fetal body is raised upward by the sling in a large arc. While strong, controlled expulsive efforts by the mother are most helpful, some traction is also required for the delivery. This is accomplished by downward pressure of the fingers on the shoulders. The assistant holding the fetus by a sling may also hold the feet, and pull gently as the body describes its arc. The fetal body should stay in a neutral position with regard to the head, avoiding hyperextension. Ultimately, the body becomes upside down and vertical, and at this point an assistant must hold the feet to prevent the fetus from falling on the floor.

As the mouth and nose appear over the perineum they may be suctioned. The cranial vault then delivers by further flexion. The operator may use a Ritgen technique on the perineum. As the head finally emerges, the infant’s body actually flips over past vertical onto the mother’s abdomen.

Extraction of a breech at cesarean delivery requires maneuvers similar to those used in vaginal birth. Thus cesarean delivery of a breech gives an opportunity for the surgeons to practice. The goal of cesarean delivery with a breech is to afford a gentle delivery. If the uterine or abdominal incisions prove to be too small for easy delivery, they can be enlarged. This is not an option during vaginal birth.

Piper Forceps Piper forceps are specifically designed to deliver the aftercoming head of a breech. They are very long, and have an axis traction curve built in. It is impossible to determine if a Piper application is “good” or “bad” on the fetal skull. Therefore, they are always applied the same way: straight to the maternal pelvis as if the position were OA. The blades are springy and grasp the fetal head in a non-specific basket catch that has proved safe and effective.

Forceps are indicated when the MSV maneuver fails. Although strict guidelines are lacking, one should consider Piper forceps if two or three minutes have passed without progress while attempting the MSV maneuver. Pipers may also be applied prophylactically if a fetus is believed to be fragile, such as a premature fetus. It is prudent to have the Pipers readily available for any vaginal breech delivery, but in an emergency, any forceps will do.

To apply Pipers, the fetus (including the arms) is wrapped in a sling and gently held up and to the operator’s left. The left blade is always applied first. It is held in the operator’s left hand and is applied to the left side of the mother’s pelvis (but to the right side of the fetus). Unlike other forceps applications, the operator holds the handle in a horizontal position and below the fetus. The right hand is placed in the vagina alongside the fetal head to protect the vaginal sidewalls. Then the forceps blade is insinuated between the right hand and the fetal head, following the cephalic curve of the blade around the head. Once inserted, the handle may be allowed to dangle or may be supported by an assistant.

The right blade is then inserted in a similar fashion, by grasping the handle with the right hand and sliding the blade into the vagina alongside the head, while protecting the sidewall with the left hand. The forceps should then be locked. When the right blade is applied over the left blade the lock will articulate normally. The handles are usually separated slightly away from the lock, and should not be squeezed together. Since the operator cannot determine how the blade is applied to the fetal skull and face, no effort is made to do so.

12 — — Chapter G: Malpresentations, Malpositions, and Multiple Gestation With the application completed, delivery of the head may commence. The operator applies a small amount of traction to the forceps. Since the shanks of the forceps have a large axis traction curve built in, no special maneuvers such as the Pajot maneuver are required to ensure that traction is in the correct vector. The primary motion of the forceps is to raise the handles in a large arc, starting about horizontal and ending at or past vertical. This arc will flex the head through the pelvis with exactly the same geometry as the MSV maneuver, but with greatly increased leverage due to the length of the forceps. None of the flexing maneuvers of the MSV maneuver are required when the Pipers are used. The fetus may be held in the sling or laid on the shanks of the forceps during the delivery.

The principal difficulty in applying Pipers is a result of the condition that indicates their use: that is, failure of the MSV maneuver implies a tight fit of head to pelvis. There may be insufficient room to place a hand alongside the head. In this situation the blade must be applied “blind” with risk of injury to mother and fetus. Once the Pipers are on, delivery can be accomplished in almost every case.

Complications of Breech Delivery A nuchal arm may occur, that is, one or both arms may be extended upward behind the neck, which may impede delivery of the head. In this event there are three delivery options. If the fetus is small or the pelvis large, the head and extended arm may be delivered together. Alternatively, the operator may attempt to flex the arm and sweep it down over the face and chest. As a maneuver of last resort the operator may rotate the fetus 360 degrees in the direction that will sweep the arm out of its nuchal position (clockwise for a left nuchal arm, counterclockwise for a right nuchal arm).

Entrapment of the aftercoming head by the cervix is another serious complication of breech delivery. This situation occurs primarily in premature and footling breeches in which the body has slipped through an incompletely dilated cervix. The head, being the largest part, becomes entrapped by the cervix. The problem is most severe in a nulliparous woman, whose cervix has never been fully dilated. slide 32 Resolution without excessive traction may require cutting the cervix, a procedure known as Dührssen’s incisions. Ring forceps are placed in pairs, parallel to each other at 2:00, 10:00 and if possible 6:00, extending three to four centimeters into the cervix. A radial incision is made between the ring forceps of each pair. Anesthesia and exposure are major technical problems, and hemorrhage is a major potential complication. This procedure is recommended only in the most extreme life-threatening circumstances.

Hydrocephalus may present as a breech delivery with an entrapped head. The appearance of a meningomyelocele or spina bifida may herald the hydrocephalus, occurring in about a third of such cases. Although prenatal diagnosis will call for highly individualized management and probable cesarean delivery, the unexpected diagnosis at the time of a breech delivery presents a significant dilemma. Decompression of the fetal ventricles or cephalocentesis may be prejudicial to the fetus, but the only way for the delivery to be completed. This procedure may be accomplished with a long needle either transvaginally or transabdominally.

— Chapter G: Malpresentations, Malpositions, and Multiple Gestation — 13 TRANSVERSE LIE OR SHOULDER PRESENTATION In transverse lie the long axis of the fetus is approximately perpendicular or at right angles to that of the mother. In the back down transverse lie or shoulder presentation, the shoulder is over the pelvic inlet, the head is lying in one of the iliac fossae, and the breech in the other. Transverse lie can also occur in the back up orientation, most commonly in the second twin. Occasionally an unstable or oblique lie will be noted, in which the fetus changes from a breech or vertex to a transverse lie or assumes an intermediate lie.

Transverse lie occurs in about 0.3 percent of singleton births. The common causes of transverse lie are: unusual relaxation of the abdominal wall, preterm fetus, placenta previa, abnormal uterus (e.g. subseptate), contracted pelvis, tumor occluding the birth canal, and polyhydramnios.

Diagnosis The diagnosis of transverse lie is usually easily made by palpation. No presenting part will be felt suprapubically, and the head will be felt in the iliac fossa. On vaginal exam the pelvis will be empty. Imaging can confirm the diagnosis.

Mechanism of Labor and Management of Delivery Spontaneous birth of a full term fetus is impossible. Therefore, cesarean delivery is mandatory in most cases. If transverse lie is encountered before the onset of labor and rupture of membranes, an attempt at external cephalic version is reasonable assuming there are no contraindications to vaginal delivery, such as placenta previa.

If a fetus presents with a back-up transverse lie and a fully dilated cervix, such as might be the case with a second twin, then either external cephalic version or internal podalic version may be contemplated. This is described in the section on multiple gestation.

When labor ensues with a back down transverse lie, the shoulder is forced into the pelvis, and an slide 33 arm may prolapse. With continued labor a retraction ring develops. Ultimately, in a neglected labor, the uterus ruptures and the mother and fetus risk death. This scenario is rarely seen in modern obstetrics but may be encountered in parts of the world where access to care is a problem.

Cesarean delivery for a back down transverse lie may require a low vertical incision in order for the operator to successfully deliver one of the fetal poles through the uterine incision.

FACE PRESENTATION In a face presentation, the head is hyperextended so the occiput is in contact with the fetal back, and the face is the presenting part. The fetal skull diameter that presents to the pelvis is the sub- mentobregmatic, which is favorable for delivery in most cases. The reference point on the fetus is the chin (mentum). Face presentation occurs in 0.1 to 0.2 percent of singleton deliveries.

The causes of face presentation are numerous and often obscure. When the fetus is very large or the pelvis is contracted, there is a predisposition to extension of the fetal head. The pendulous abdomen of a grand multipara also promotes extension of the fetal head. In exceptional instances, enlargement of the neck because of goiter or cystic hygroma, or numerous coils of cord around the neck may cause extension. Anencephalic fetuses often present by the face because of absent development of the cranium.

14 — — Chapter G: Malpresentations, Malpositions, and Multiple Gestation Diagnosis The clinical diagnosis of a face presentation relies principally on the vaginal exam. The mouth, nose, and the malar prominences may be palpated. A face presentation may be confused with a breech presentation, particularly since breech is 20 times more common. The mouth may be mistaken for the anus, and the malar prominences mistaken for the ischial tuberosities. The anus and ischial tuberosities of a breech form a straight line, whereas the mouth and malar prominences of a face form a triangle. The exam may be very confusing due to edema of the facial structures, even for the most experienced practitioner. Imaging will confirm the diagnosis and rule out anencephaly.

Mechanism of Labor slide 34 The key for successful delivery of a face is for the chin to end up under the symphysis, or be in mentum anterior position. Then, with further descent of the fetus, the cranial vault can sweep through the posterior pelvis and the head can be born by flexion.

Although this mechanism does not present the most favorable diameter of the fetal head to the pelvis, if the fetus is not too large and the pelvis is adequate, spontaneous delivery can occur. If the chin slide 35 rotates or remains posteriorly (mentum posterior) then there is no mechanism that allows the fetus to utilize the space in the posterior pelvis in the hollow of the sacrum, and delivery cannot occur.

Management of Delivery Spontaneous vaginal delivery may occur sometimes with surprising ease. The fetus must rotate to a mentum anterior position. A persistent mentum posterior mandates a cesarean delivery. Attempts to manually convert a face to a vertex are outmoded and dangerous, as are attempts to rotate a mentum posterior to a mentum anterior. Forceps however, can be safely and successfully applied to a mentum anterior that is on the perineum. The vacuum extractor is absolutely contraindicated. Likewise, scalp electrode internal monitoring is contraindicated, to avoid injuring the face. Oxytocin augmentation should be used only with extreme caution, and is usually considered contraindicated. A large episiotomy may be recommended to accommodate the vertex coming through the posterior pelvis. Parents should be prepared for the dramatically bruised and edematous face of the infant, but recovery is prompt.

BROW PRESENTATION In a brow presentation the portion of the fetal head between the orbital ridge and the anterior fontanel presents at the pelvic inlet. The fetal head is in an attitude between full flexion and full extension (or face). The presenting diameter of the fetal skull is the occipitomental, which is very unfavorable for delivery. Delivery of a persistent brow usually cannot take place unless the fetus is very small or the pelvis is very large.

Brow presentation is found in 0.02 percent of singleton deliveries. The causes of this rare presentation are similar to those for face presentation. A brow presentation is usually unstable and will convert either to a face or a vertex presentation.

Diagnosis Diagnosis is by vaginal exam. The frontal sutures, anterior fontanel, orbital ridges, eyes, and root of the nose may be felt. Frequently the exam is confusing because of edema and unfamiliarity of the presenting features.

— Chapter G: Malpresentations, Malpositions, and Multiple Gestation — 15 Mechanism and Management of Labor A persistent brow cannot deliver vaginally under normal conditions. If it converts to vertex or face, then delivery may occur according to their respective mechanisms. In the absence of conversion and progress in labor, cesarean delivery is required.

COMPOUND PRESENTATION In a compound presentation an extremity, usually a hand, prolapses alongside the main presenting slide 36 part, usually the head. Compound presentation occurs in 0.04 to 0.14 percent of deliveries. Often no cause is found. It is more common with premature infants and when the fetal presenting part does not completely occlude the pelvic inlet.

Diagnosis The diagnosis is usually readily made on vaginal exam. It is critically important to distinguish between a hand and a foot prolapsed alongside the head.

Management of Delivery As long as labor is progressing normally, no intervention is necessary. Most commonly the prolapsed limb will deliver spontaneously along with the head, or sometimes the fetus will retract its limb spontaneously. If the prolapsed arm appears to be impeding descent, it should be gently elevated upward and the head manipulated simultaneously downward.1 (Category C) Occasionally cesarean delivery will be necessary. The parents should be warned to expect bruising and edema of the prolapsed extremity.

PROLAPSE OF THE UMBILICAL CORD slide 37 Prolapse of the umbilical cord is a true obstetrical emergency. The cord may become compressed or occluded between the presenting part of the fetus and the pelvic brim or sidewall resulting in asphyxia and death. The incidence of cord prolapse is 0.4 percent in vertex presentations, 0.5 percent in frank breeches, four to six percent in complete breeches, and 15 to 18 percent in footling breeches. Cord prolapse is most common when the fetus does not occlude the pelvic inlet well, as is the case with a footling breech. Other factors that may contribute to cord prolapse are prematurity, polyhydramnios, high presenting part, and a long cord. Occasionally the cause is iatrogenic, as for example slide 38 when the membranes are ruptured with the presenting part high out of the pelvis. A gush of fluid may then wash the cord down into the vagina. On the other hand, the cord may have already been coiled beneath the fetal presenting part (occult cord prolapse) such that rupture of the membranes merely revealed the prolapse, but did not cause it.

Rapid identification and response may truly save the life of the fetus. The management steps are: slide 39 1. Diagnose the cord prolapse by visual inspection or palpation on immediate vaginal exam. The cord may be found extruded from the vagina, coiled in the vagina, or wrapped across the presenting part. The only hint may be a severe variable deceleration or bradycardia following rupture of the membranes. 2. Quickly assess the fetal status by monitoring or ultrasound. 3. Assess the dilation and status of labor. If the fetus can be delivered more quickly and safely per vagina than by cesarean delivery, then proceed immediately using forceps, vacuum or total breech extraction as appropriate.

16 — — Chapter G: Malpresentations, Malpositions, and Multiple Gestation 4. If immediate vaginal delivery is not feasible then prepare for cesarean delivery. Elevate the presenting part out of the pelvis in an effort to protect the cord from occlusion. This may be performed by placing a hand in the vagina and forcefully (but carefully) elevating the presenting part upward. Alternatively, some success has been achieved by filling the bladder rapidly with 500 to 700 cc of saline. Tocolysis (e.g. terbutaline 0.25 mg subcutaneously) is helpful if the patient is in labor. Deep Trendelenburg position also is useful to add gravity to other efforts to elevate the fetus off the cord. The efficacy of these maneuvers can be measured by monitoring the fetus or palpating the cord. 5. Do not attempt the futile tactic of attempting to replace the cord in the uterus. 6. Perform an emergent cesarean delivery while continuing all efforts to hold the presenting part off the cord. 7. If delay is encountered, wrap the cord in warm wet packs. Prevention of cord prolapse is difficult but may be accomplished on occasion by identifying risk factors or by identifying a cord presentation by ultrasound. Artificial rupture of the membranes should not be done when the station is high. If artificial rupture of membranes is essential to manage a difficult obstetric situation, and the head is unengaged and high, the membranes can be needled under double set-up conditions. The same procedure can be used to rupture the membranes in cases of polyhydramnios.

Patients in the latter stages of pregnancy who are at high risk for cord prolapse (e.g. footling breech, polyhydramnios) can be identified. They can be instructed to examine themselves for cord prolapse if their membranes rupture out of hospital. If a prolapse is identified, they should assume a deep knee-chest position and maintain the position even during transport to the hospital.

MULTIPLE GESTATION Multiple gestation occurs in approximately 1.5 percent of births in the United States. Perinatal morbidity and mortality are increased two to five fold, largely due to prematurity. Congenital anomalies, IUGR, and intrapartum complications also contribute. Dizygosity (fraternal twinning) occurs in about two thirds of twin gestations, and is increased with age, parity, and certain familial and racial circumstances. Monozygosity (identical twinning) occurs in one third of twin gestations and is unrelated to any predisposing factors. Morbidity and mortality are higher in monozygotic twins.

Maternal complications are common in multiple gestation. These include pregnancy induced hypertension, anemia, hyperemesis, abruption, placenta previa, postpartum hemorrhage, and increased operative delivery.

Diagnosis The routine use of ultrasound has greatly diminished the difficulties of diagnosing multiple slide 40 gestation. Historical and physical findings suggestive of multiple gestation and indicating an ultrasound exam are: uterus larger than dates, hyperemesis gravidarum, early PIH, elevated maternal serum alpha feto-protein (MSAFP), suggestive palpatory or auscultory findings, polyhydramnios, ovulation induction, and family history.

— Chapter G: Malpresentations, Malpositions, and Multiple Gestation — 17 Prenatal Management Several issues distinguish multiple gestations from singleton pregnancies: slide 41 1. Prematurity is the greatest threat to multiple gestation infants, and prevention of prematurity is of the highest priority. Unfortunately, no preventive measures, including bed rest and tocolytics, have been clearly effective in preventing premature labor. The best approach appears to be attentive general support. 2. Compared to singletons, congenital anomalies and developmental defects are doubled in all twin pregnancies, and higher yet in monozygotic twin pregnancies. Ultrasound, and in some cases amniocentesis, should be considered. Monoamniotic twinning, which may be diagnosed by ultrasound, presents a very high risk situation due to cord entanglement. 3. Compared to singletons, pregnancy induced hypertension is doubled in twin gestations. Active surveillance and management are recommended. Iron deficiency is common, and iron supplementation is generally indicated. The possibility of intrauterine growth restriction (IUGR) and discordant growth requires surveillance. IUGR has been reported from 12 to 47 percent and discordancy from four to 23 percent, depending on the standard used (15 to 25 percent difference in weight using the larger twin as reference). Ultrasound exams every four weeks are recommended for early diagnosis. Intervention in the presence of significant discordancy is a complicated issue, and beyond the scope of this chapter. 4. Fetal death occurs in 0.5 to 6.8 percent of twin pregnancies. Conservative management of the surviving twin is indicated, at least until lung maturity is proven. The patient should be monitored for development of coagulopathy. 5. The incidence of placenta previa is increased in multiple gestations, possibly because of the larger surface area of the two placentas.

Certain complications of pregnancy do not seem to be increased in multiple gestations. These include diabetes, pyelonephritis, and third trimester bleeding.

Intrapartum Management No obstetric situation presents a greater range of challenges than multiple gestation. Only the most skilled and confident obstetric providers should plan to attend twin deliveries without backup.

Intrapartum complications include malpresentations, locking of twins, cord prolapse, abruption, non-reassuring fetal heart rate tracing, dysfunctional labor, and postpartum hemorrhage. Several of these complications can arise from the manner in which the twins present. Either fetus may be vertex, breech or in a transverse lie. Theoretically there are nine combinations of presentation of twins slide 42 A and B, but for practical purposes there are three.

Presentation of Twins Twin A Twin B Occurrence (percent)

Vertex Vertex 43 percent Vertex Non-vertex 38 percent Non-vertex NA 19 percent

18 — — Chapter G: Malpresentations, Malpositions, and Multiple Gestation Vertex-vertex presentations are the most common and least complicated. With appropriate monitoring and the capability to respond to an emergency, labor may be allowed to progress to vaginal delivery of both infants. Oxytocin induction or augmentation, epidural anesthesia, and other interventions are all acceptable with caution. The interval between deliveries is not critical as long as the second fetus is doing well, but oxytocin augmentation is often used when delay is encountered between deliveries.

When twin A is vertex, but twin B is non-vertex, controversy exists as to the best mode of delivery. Although many practitioners advocate cesarean delivery, it is not always necessary in this situation. Vaginal delivery of twin B in the nonvertex presentation is a reasonable option for a neonate with an estimated weight greater than 1,500 gm as long as criteria for vaginal delivery of a singleton breech are met.19 Cesarean delivery of a second twin not presenting cephalically has yet to be demonstrated to improve neonatal outcome.20 (Category A) A policy of routine cesarean delivery should not be adopted without further controlled trials. slide 43 When vaginal delivery is attempted, the crisis point occurs after the delivery of twin A, at which time the physician must determine the presentation of twin B (which may be different from its presentation before twin A was born). A combination of external exam, internal exam, and ultrasound may be used. Assuming twin B is breech or in a transverse lie, a decision must then be made whether to 1) attempt an external version to vertex; 2) deliver twin B as a breech; or 3) perform a cesarean delivery. The exact obstetric circumstances, the experience of the operator, condition of the fetus, state of mind of the mother, and the available resources are all factors in the decision.

External cephalic version is frequently successful, easy, and safe, as the uterus is often very relaxed after delivery of twin A, and there is plenty of room for twin B to turn. Once the vertex has been placed over and guided into the inlet manually, the membranes can be ruptured or oxytocin augmentation given (or both) and a vertex delivery should ensue.

A breech delivery is also a possibility for twin B. This may be inadvisable for very small fetuses, but macrosomia with difficult delivery is rarely a problem in the second twin. Breech delivery is a reasonable choice in the following circumstances: 1. When external version is unsuccessful or not attempted . 2. When labor is strong and the second fetus presents with the breech deep in the pelvis, in which case external version is not likely to succeed and prompt delivery is anticipated. 3. When emergencies such as cord prolapse or a non-reassuring FHR tracing occur, and a skilled operator is available to perform a breech extraction.

Occasionally twin B presents as a transverse lie with the back up and the feet dangling towards the cervix. In this situation, a procedure known as internal podalic version may be appropriate. The operator grasps both feet firmly through the membranes and pulls the feet into the vagina. An assistant helps rotate the fetus into proper position abdominally. With the operator exerting steady downward traction on the feet to maintain the breech as the presenting part, the membranes are then ruptured. The delivery then proceeds as a breech. This is probably the most difficult and dangerous procedure permissible in modern obstetrics.

— Chapter G: Malpresentations, Malpositions, and Multiple Gestation — 19 Cesarean delivery may be required for a non-vertex twin B. Situations mandating Cesarean delivery include a non-reassuring fetal heart tracing, cord prolapse, abruption, or rupture of the membranes trapping the fetus in a transverse lie. A contributing problem occurs when the cervix “closes down” after twin A is born. These situations can arise suddenly, so resources for immediate cesarean delivery should be available.

When twin A is non-vertex, cesarean delivery is generally required for safety. External cephalic version of a breech twin A is not technically feasible. When twin A is breech and twin B is vertex or transverse, locking or collision of the twins is a disastrous event.

Cesarean delivery in multiple gestation presents anesthetic and surgical challenges due to the enlarged uterus, the exaggerated physiologic response to pregnancy, and the potential for exotic presentations of the fetuses. The necessity for a vertical incision in both skin and uterus is a special consideration when the twins are in unusual or entwined positions. Conjoining of twins is a rare problem beyond the scope of this chapter, but should always be considered if ultrasound shows twins “face to face” or “back to back.”

Undiagnosed twins are rare in areas where ultrasound is frequently used. However, in the pre- ultrasound era, as many as 50 percent of twins were unsuspected until after delivery of twin A. Therefore, when no ultrasound has been performed, birth attendants should always be alert for this possibility.

After delivery, postpartum hemorrhage is relatively common due to the overdistension of the uterus. Providers should be fully prepared with intravenous access, proper oxytocics, and readily available blood products.

Neonatal resuscitation is often required due to prematurity or the many potential complications of multiple gestation. Not uncommonly, two infants need attention simultaneously. Adequate personnel and equipment must be available.

SUMMARY slide 44 There are six types of malpresentations. Some are common (occiput posterior presentation, breech) and some are rare (transverse lie, brow, face, compound presentation). Diagnosis is made by a combination of physical examination and imaging. A high index of suspicion is helpful in making the diagnosis. Each type of malpresentation has its complications. Providers should be alert not only for complications resulting from labor and delivery, but also for problems that may be etiologic for the malpresentation in the first place.

Vaginal delivery may be considered for four of the six malpresentations: occiput posterior presentation, breech, face, and compound presentation. With occiput posterior presentation, the provider has several management choices for delivery. With breech, complex criteria determine if vaginal delivery can occur safely. External cephalic version can prevent breech presentation at term. A high degree of technical skill and judgment is required to deliver patients with malpresentations safely. Multiple gestation presents a wide variety of special challenges to the provider.

20 — — Chapter G: Malpresentations, Malpositions, and Multiple Gestation SUMMARY OF RECOMMENDATIONS Category A Women with breech presentation who meet standard criteria near term should be offered an attempted external cephalic version.9,10,12 Caesarean section for delivery of a second twin not presenting cephalically as yet has not identified improvement in neonatal outcome.20

Category B Thirty seven weeks appears to be the optimal gestational age for ECV.9,10 Cesarean delivery does not prevent all infant morbidity in breech presentation.14,15

Category C The conduct of labor and delivery with a persistent OP is not markedly different from that of the fetus in the occiput anterior position.1 In an OP rotation, the hand should be used which pronates during the rotation (like closing a book): left hand for ROP and right hand for LOP.4 Various exercises and positions have been tried in an attempt to turn a breech and no difference in outcome has been noted in either a postural management group or a control group.6,7 When performing ECV, facilities and personnel must be available for performing an immediate cesarean delivery.13 There is insufficient evidence to recommend routine tocolysis for ECV for multiparous patients.12 In a compound presentation, if the prolapsed arm appears to be impeding descent it should be gently elevated upward and the head manipulated simultaneously downward.1

— Chapter G: Malpresentations, Malpositions, and Multiple Gestation — 21 REFERENCES

1. Cunningham, MacDonald, Gant, et al (eds). Williams 15. Hofmeyr GJ, Hannah ME. Planned Caesarean sec- Obstetrics, 20th Edition, 1997; Appleton & Lange, tion for term breech delivery (Cochrane Review). In: Stamford, CT, Chapter 18: Dystocia – Abnormal The Cochrane Library, Issue 1, 2000. Oxford: Update presentation, position, and development of the fetus. Software. (Level I) pp 448-449. (Level III) 16. Zatuchni GI, and Andros GJ. Prognostic Index for 2. Cruickshank DP. Malpresentations and Umbilical vaginal delivery in breech presentation at term. Cord Complications. In: Danforth’s Obstetrics and Am J Obstet.Gynecol 1965;93:237. (Level III) Gynecology, Sixth edition, Scott JR, DiSaia PJ, 17. Hannah, M and others for the Term Breech Trial Hammond CB, and Spellacy WN (eds); J.B Lippincott Collaborative Group. What is the best way to deliver Company, 1990. (Level III) a breech baby? Lancet 2000;356:1375-83. (Level I) 3. Pearl ML, Roberts JM, Laros RK, and Hurd WW. Vaginal 18. The Society of Obstetricians and Gynaecologists of delivery from the persistent occiput posterior position. Canada. SOGC Interim Position on Management of Journal of Reproductive Medicine 1993;38(12):955-960. Term Breech. September 27, 2000. (Level III) (Level II-2) 19. Special Problems of Multiple Gestation. ACOG 4. Cunningham, MacDonald, Gant, et al (eds). Williams Educational Bulletin No. 253, November 1998. Obstetrics, 20th Edition, 1997; Appleton & Lange, page 807. (Level III) Stamford, CT, Chapter 18: Dystocia – Abnormal presentation, position, and development of the fetus. 20. Crowther CA: Caesarean delivery for the second twin pp 482-483. (Level III) (Cochrane Review). In: The Cochrane Library, Issue 1, 2000. Oxford: Update Software. (Level I) 5. Scheer K, Nubar J: Variation of fetal presentation with gestational age. Am J Obstet Gynecol 1976;125:269. (Level III) 6. Hofmeyr GJ, Kulier R. Cephalic version by postural management for breech presentation (Cochrane Review). In: The Cochrane Library Issue 3, 1999. Oxford: Update Software. (Level I) 7. Smith C, Crowther C, Wilkinson C, Pridmore B, and Robinson J. Knee-chest postural management for breech at term: A randomized controlled trial. Birth 1999;26(2):71-75. (Level I) 8. Cunningham, MacDonald, Gant, et al (eds). Williams Obstetrics, 20th Edition, 1997; Appleton & Lange, Stamford, CT, Chapter 18, pp 442-443. (Level III) 9. Hofmeyr GJ, Kulier R. External cephalic version for breech presentation at term (Cochrane Review). In: The Cochrane Library, Issue 3, 1999. Oxford: Update Software. (Level I) 10. External Cephalic Version. ACOG Practice Bulletin, Feb. 2000; No.13:1-6. (Level III) 11. Flamm BL, Fried MW, Lonky NM and Saurenman Giles W. External cephalic version after previous cesarean delivery. Am J Obstet Gynecol 1991;165(2):370-372. (Level II-2) 12. Hofmeyr GJ. External cephalic version facilitation for breech presentation at term. The Cochrane Library, Issue 1, 2000. Oxford: Update Software. (Level I) 13. Zhang J, Watson AB, and Fortney JA. Efficacy of external cephalic version: A review. Obstetrics & Gynecology 1993;82(2):306-312. (Level III) 14. Danielian PJ, Wang J, and Hall MH. Long term outcome by method of delivery of fetuses in breech presentation at term: Population based follow up. Br Med J 1996;312:1451-1453. (Level II-2)

22 — — Chapter G: Malpresentations, Malpositions, and Multiple Gestation Chapter H

Assisted Vaginal Delivery slide 1 James R. Damos, MD Christopher J. Frank, MD

Published August 2010 slide 2 OBJECTIVES After completing this chapter, participants will be able to: 1. Discuss the indications for assisted vaginal delivery. 2. Discuss the prerequisites for the use of vacuum extraction and forceps. 3. Define outlet, low, and mid instrument procedures. 4. Name the parts of the obstetrical vacuum extractor and Simpson forceps. 5. Demonstrate proper use of vacuum and forceps equipment on a maternal-fetal mannequin. slide 3 INTRODUCTION Assisted vaginal delivery, either with vacuum extraction or forceps, is an important skill for managing the second stage of labor. Each labor is a dynamic event, and may require emergent or elective assisted vaginal delivery when maternal efforts fail to effect delivery or when there are non-reassuring fetal heart tones. Situations that require immediate and competent use of vacuum or forceps can arise quickly even in low-risk labors. Family physicians practicing in rural communities may not have obstetric backup when an assisted vaginal delivery is required. Even family physicians practicing in more urban areas may not have an obstetrician readily available for assistance in an emergency. slide 4 The rate of operative vaginal delivery has steadily dropped in the United States from nine percent of live births in 1990 to 4.5 percent of live births in 2006.1 Vacuum deliveries now comprise 3.7 percent of live births.1 Forceps assisted deliveries now comprise only 0.8 percent of live births.1 The decrease in operative vaginal deliveries has decreased training opportunities during residency for both family physicians and obstetricians. One survey of chief residents in obstetrics and gynecology residencies in the United States suggests that only 50 percent of senior trainees felt competent to use forceps.2 In spite of decreased training opportunities, physicians who practice maternity care, whether in rural or urban areas, should be able to rapidly and safely perform a vacuum extraction or forceps when an urgent assisted vaginal delivery is needed. slide 5 PREVENTION The use of epidural analgesia increases the rate of instrument assisted vaginal delivery, but does not increase the rate of cesarean delivery.3 In patients without epidural anesthesia the rate of assisted vaginal delivery can be reduced with the use of any upright or lateral position, compared with supine or lithotomy positions. Specifically the use of any upright or lateral position was associated with reduced duration of second stage of labor, a small reduction in assisted deliveries, but a small increase in second-degree perineal tears.4 (Category A) The continuous presence of a support person was associated with a slight reduction in the length of labor and reduced the likelihood of operative vaginal delivery.5 (Category A)

— Chapter H: Assisted Vaginal Delivery — 1 Primiparous women with epidural analgesia may benefit from oxytocin augmentation in the second stage of labor. A randomized trial of the use of oxytocin at the onset of the second stage in 226 primiparous women with an epidural and no previous use of oxytocin during labor was associated with a decrease in the need for assisted vaginal delivery (NNT = 12) and cesarean delivery rates (NNT = 65).6

Placing arbitrary limits on the appropriate length of the second stage can increase the rate of assisted vaginal deliveries. Recent studies have demonstrated the safety of continuing the second stage as long as progress is being made and there is no evidence of fetal compromise.7,8

INSTRUMENTS slide 6 Originally, vacuum devices had a rigid metal cup with a separate suction catheter attached laterally and connected to a foot-operated pedal. Today’s vacuum cups can be soft or rigid and can be different shapes and sizes. Rigid posterior cups (Kiwi Omnicup [Figure 1A], Mityvac M-cup, and Bird or O’Neil cups) have been designed for occipitoposterior and asynclitic deliveries. The flatter cup allows for better placement at the flexing position on the fetal head, which is usually much further back in the sacral hollow during occipitoposterior presentation. Newer devices allow for an assistant to hand-pump suction using a separate device (Figure 1B) or for the user to hand-pump suction with a single handheld device (Figure 1C). In the United States, these handheld devices are intended for single use and are disposable. A Cochrane review of nine trials comparing soft and rigid cups showed that soft cups were significantly more likely to fail to achieve vaginal delivery (OR = 1.65; 95% CI, 1.19 to 2.29).9 Failure rates were 10 percent with rigid cups and 22 percent with soft cups. Soft cups, however, were associated with less scalp injury (OR = 0.45; 95% CI, 0.15 to 0.60).9 There were no significant differences in maternal injury.9 The specific vacuum device use in an ALSO course may vary based on local practices patterns, however familiarity with both a rigid posterior cup for OP and asynclitic deliveries as well as the soft cup is encouraged.

Figure 1 A Figure 1 B Figure 1 C

As with vacuum, there are many types of forceps that are suited for different uses (Piper, Elliott, Kielland etc.). Simpson forceps are adaptable forceps that are available on most labor and delivery units, and are suitable for use with large, molded fetal heads. The ALSO course has chosen the Simpson forceps to teach outlet delivery.

2 — — Chapter H: Assisted Vaginal Delivery INDICATIONS AND PREREQUISITES FOR INSTRUMENT DELIVERY The major indications for the use of assisted vaginal delivery in the second stage of labor are prolonged second stage, maternal indications (exhaustion, maternal medical illness like cardiac disease) and non-reassuring fetal heart tones.

Prolonged Second Stage slide 7 A prolonged second stage is defined in Table 1. These arbitrary limits are not based on strong supporting data and more recent studies have demonstrated the safety of continuing the second stage as long as progress is being made and there is no evidence of fetal compromise.7,8

There are many causes of a prolonged second stage and some are more safely managed by assisted vaginal delivery than others. A prolonged descent due to soft tissue resistance or the effect of epidural analgesia is less of a concern than descent that is slowed due to relative cephalopelvic disproportion (bony pelvis-fetal disproportion), malposition (occiput posterior, occiput transverse, or malpresentation (face-mentum anterior delivered by forceps only).

Table 1. Intervals for Defining Prolonged Second Stage

Parity Without Regional Anesthetic With Regional Anesthetic

Nullipara two hours three hours

Multipara (parous) one hour two hours

Maternal Indications slide 8 1. Inability to push (maternal exhaustion) This occurs occasionally if stage one or stage two labor is prolonged. Other factors associated with maternal fatigue include starting to push too soon in the labor process and the absence of a labor support companion.5 Second stage management is as important as first stage labor care. Labor augmentation in the second stage may be an important intervention to decrease the rate of assisted vaginal delivery or cesarean section.10,11 (Category C) Additionally, if no urge to push is obvious in the early second stage of labor, caregivers may defer active encouragement of maternal expulsive effort to avoid exhausting the mother until further descent of the fetus increases her involuntary urge. 2. Drug-induced analgesia (i.e. epidural anesthesia) may also result in interference with the woman’s voluntary expulsive efforts.3 In women with epidural anesthesia, it may be beneficial to have the mother refrain from actively pushing until after a period of passive descent of the vertex.12 3. Maternal illnesses Intensive valsalva may be contraindicated in cases of maternal cardiorespiratory or intracranial disease, necessitating the use of instrumentation in the second stage.

Non-reassuring fetal status slide 9 This includes evidence of immediate or impending fetal compromise including category III and some Category II fetal heart rate tracings which fail to respond to conservative measures or evidence of abruption during the second stage of labor.

— Chapter H: Assisted Vaginal Delivery — 3 PREREQUISITES TO INSTRUMENT DELIVERY slide 10 Certain conditions must exist before an instrument delivery is attempted.13,14 (Category C) These are: 1. A vertex presentation of the head with pelvic engagement. 2. Complete dilation of the cervix. 3. Rupture of the amniotic membranes. 4. No suspected severe cephalopelvic disproportion. 5. A willingness to abandon the procedure if it does not go well.

DEFINITIONS slide 11 Engagement is defined as the passage of the biparietal diameter of the fetal head through the plane of the pelvic inlet. Clinical evidence of engagement on examination, by definition, is when the leading edge of the fetal skull is at or below the ischial spines. The distance between the ischial spines and the pelvic inlet is ordinarily believed to be greater than the distance between the leading edge of the fetal skull and the biparietal diameter. However, after vigorous labor, the fetal skull may be elongated and molded with caput formation.

Zero station does not prove engagement, especially with a posterior presentation or a large degree of molding.13 Clinicians can improve upon their clinical estimate of engagement by feeling how much of the fetal head is above the upper level of the pubic symphysis with the abdominal hand. When the fetal head is “just engaged”, the head may be palpated with the fingers on one side only. The occiput may not be palpated above the upper border of the symphysis pubis. The head is deeply engaged when neither the sinciput nor occiput are palpable above the upper border of the symphysis pubis. Because of the difficulties of clinically estimating engagement and confusion surrounding terminology of stations for mid-instrument application, the American College of Obstetricians and Gynecologists reclassified instrument deliveries as follows:14

1. Outlet forceps or vacuum — The fetal skull has reached the pelvic floor. The scalp is visible slide 12 between contractions. The sagittal suture is in the anterior-posterior diameter or in the right or left occiput anterior or posterior position, but not more than 45 degrees from the midline. 2. Low forceps or vacuum — The leading edge of the fetal skull is station +2 in centimeters or more. The head is not on the pelvic floor. Rotations are divided into 45 degrees or less and more than 45 degrees. 3. Mid forceps or vacuum — The head is engaged, but the leading edge of the skull is above +2 station in centimeters. The term “high forceps or vacuum” has been eliminated.

INSTRUMENT CHOICE slide 13 In the United States, the vacuum extractor is becoming the preferred instrument when assisted delivery is indicated. Instrument choice will depend mostly on the experience of the operator. The vacuum is easier to apply. Vacuum-assisted delivery teaches the clinician to follow the pelvic curve. It applies less force to the fetal head although this may be a liability when rapid delivery is essential. Vacuum results in less maternal trauma although its use is associated with an increase in cephalohematoma and retinal hemorrhages.15 Vacuum extraction is more likely to fail than forceps,15 but also is less likely to lead to 3rd and 4th degree perineal lacerations.16 A retrospective review of 50,210 vaginal deliveries at a single institution showed the rate of third and fourth-degree laceration increased from 9.3 percent with vacuum to 19.2 percent with forceps.16 Occiput posterior position

4 — — Chapter H: Assisted Vaginal Delivery can present a challenging choice as vacuum will fail more often, however the incidence of anal sphincter lacerations with an occiput posterior forceps application is quite high.17

Forceps have been viewed as having the ability to achieve a more rapid delivery 18 than vacuum; however a recent study found them to be equivalent.19 In addition, forceps can be used for a mentum anterior face presentation and piper forceps for the aftercoming head in a breech presentations. The relative safety of vacuum vs. forceps for assisted vaginal delivery was assessed in a randomized controlled trial of 313 women. After five years there was no evidence of a difference in maternal or fetal outcomes.20 Incidence of severe birth trauma following assisted deliveries has slide 14 been evaluated. The lowest risk of fetal injury was found in infants delivered spontaneously. An intermediate risk was observed for those infants delivered by forceps or vacuum alone or by cesarean delivery during labor. The highest risk of fetal injury was reported for those infants who were delivered with combined forceps and vacuum extraction or who were delivered by cesarean following failed operative vaginal delivery. There was no difference in outcome between vacuum and forceps delivery versus cesarean delivery during labor.21 The fetal injury rate among infants delivered by cesarean delivery before labor was not higher, suggesting that the common risk factor for intracranial hemorrhage is abnormal labor.21

APPLICATION OF THE VACUUM INSTRUMENT For the beginner, the acronym ABCDEFGHIJ, developed by Dr. J. Bachman in 1989, and modified here may be useful.22 slide 15 A = A sk for help, Address the Patient, and is Anesthesia adequate? Local anesthesia is usually all that is needed if any. B = Bladder empty C = Cervix must be completely dilated. slide 16 D = D etermine position and think shoulder dystocia. Review the HELPERR mnemonic.

Throughout the first stage of labor, it is important to determine the fetal head position. It becomes increasingly difficult to make this determination during stage two labor, as the fetal caput develops. In determining position, one should remember that: 1. The anterior fontanel is larger and forms a cross. 2. The posterior fontanel is smaller and forms a Y. 3. The clinician can feel for an ear and see which way it bends. 4. Molding should be assessed when thinking about dystocia. Molding is often an indication of the extent of fetal head compression and can be divided into mild, moderate, and severe. If the parietal bones are touching but not overlapped at the sagittal suture line, molding is mild. If the parietal bones are overlapping but can be easily reduced to the normal position by finger pressure, molding is said to be moderate. Severe molding exists when the overlapping of bones cannot be reduced.23 If severe molding is present, as is often found with deflexed and asynclitic heads, the additional force created by applying the vacuum extractor may increase the risk of intracranial injury in some cases.15,24 E = Equipment and Extractor ready. These should be ready and an assistant should be on hand. slide 17 F = Apply the cup over the sagittal suture and in relation to the posterior Fontanel. Feel for maternal tissue before and after appllying suction.

— Chapter H: Assisted Vaginal Delivery — 5 With the suction off, the center of the cup should be applied 3 cm anterior to the posterior fontanel, centering the sagittal suture under the vacuum). The edge of the cup will be over the posterior fontanel (most cups have a diameter of 5 to 7 cm). This point, located in the midline along the sagittal suture, approximately 3 cm in front of the posterior fontanel and approximately 6 cm from the anterior fontanel, is called the Flexion point. The flexion point is an important point in maximizing traction and minimizing detachment of the cup. Checking for placement of the cup by using the anterior fontanel as the landmark may be easier because the posterior fontanel will be obscured by the cup. No maternal tissue, including the vagina, should be under the cup. The risk of subgaleal hemorrhage increases if the cup edge is placed on the sagittal suture.25 Improper application appears to be common with attempted vacuum assisted delivery26 and is thought to be a primary factor in unsuccessful attempts.27

The vertex is wiped clean of blood and fluid. The labia are spread, and the cup is compressed and slide 18 inserted. A finger is swept around the cup to make sure no maternal tissue is trapped beneath the cup. The pressure gauge is calibrated into a yellow and green area. The manometer needle should be in the yellow area in between contractions and in the green area during contractions (usually about 10 and 50 units of Hg, respectively).

G = Gentle traction.Traction should be applied at right angles to the plane of the cup, which will slide 19 automatically be in the correct axis of traction. Axis traction is the most efficient means of effect- ing progress; the greatest progress will occur with the least amount of force. Rocking movements or torque should not be applied to the vacuum device; only steady traction in the line of the birth canal should be used in order to avoid birth trauma to the neonate.28 (Category C) As the fetal head stems under the symphysis and begins to extend, the vacuum handle will rise from approximately horizontal to almost vertical. If the shaft is bent or a rotary force is applied, the vacuum seal will likely be broken. As noted above, if the cup has not been properly applied over the flexion point, it is likely that the vacuum seal will be broken.

In most cases, traction should be applied only during contractions. An exception to this rule may slide 20 be a more urgent condition, such as abnormal fetal heart tones, where traction may be needed even without a contraction to achieve delivery quickly. This is best accomplished in the absence of cephalopelvic disproportion.

H = Halt traction when the contraction is over and reduce the pressure to 10 units by triggering slide 21 the vacuum release valve. Repeat the cycle when the next contraction begins. Some experienced clinicians advocate holding the vertex down, in between contractions. The idea is to progress when there is a contraction, and then hold the baby there, not allowing it to slip up at all, in between contractions. To do this, the pressure needs to be maintained in the green area of the dial at 50 units. No differences in outcome (time to delivery, method failure, maternal lacerations, episiotomy extension, incidence of cephalohematoma, and neonatal outcome) have been shown with intermittent reduction in vacuum pressure or attempts to prevent loss of station.28 (Category A)

Halt the procedure if you have had disengagement of the cup, ’pop offs‘ three times, or have had no progress in three consecutive pulls (remember the number three).29 (Category C) In published randomized controlled trials, it has been suggested to have no more than a 20-minute total application.30 (Category C) The proportion of fetal injuries increases significantly between 11 to 20 minutes duration, compared to less than 10 minutes.30

6 — — Chapter H: Assisted Vaginal Delivery Use caution in attempting forceps after the vacuum extractor has failed as this is associated with increased neonatal trauma.21,29,35 In many cases cesarean section is a safer option than attempting delivery with a second instrument. ACOG advises against the use of sequential instruments except in an emergency when cesarean delivery is not immediately available. slide 22 I = Evaluate for Incision for episiotomy when the head is being delivered. Although it is in the original “ABCDEFGHI J” mnemonic, performing an Incision for midline episiotomy increases the risk of perineal trauma and, therefore, is no longer recommended. Compared with nulliparous women who have spontaneous vaginal delivery without episiotomy, the odds of having a severe (third- or fourth- degree) perineal laceration are increased in women who have vacuum delivery without episiotomy (OR = 3.1; 95% CI, 1.9 to 4.3). The odds of a severe perineal laceration are even higher in women who have vacuum delivery with episiotomy (OR = 13.7; 95% CI, 10.1 to 17.3).31 Similar results were noted in multiparous women. slide 23 J = Remove the vacuum cup when the Jaw is reachable.

DISADVANTAGES OF VACUUM slide 24 Several disadvantages occur with the use of vacuum: 1. Traction can speed delivery in emergency situations only when there is cooperation from the patient with pushing and/or there is minimal cephalopelvic disproportion. Consequently, delivery may take longer than when using forceps. 2. Proper traction at right angles to the plane of the vacuum cup, and in the axis of traction, is necessary to avoid losing vacuum. 3. There is a small increase in the incidence of cephalohematoma. Predelivery factors found to predispose to neonatal cephalohematoma formation include increasing asynclitism and time from vacuum application to delivery exceeding ten minutes.30 (Category C) slide 25 NEONATAL RISKS ASSOCIATED WITH VACUUM ASSISTED DELIVERY On May 21, 1998, an FDA public advisory was published cautioning health care providers when using vacuum assisted delivery devices.32 One type of life threatening complication noted was subgaleal hematoma. slide 26 This occurs when emissary veins are damaged and blood accumulates in the potential space between the galea aponeurotica and the periosteum of the skull. Signs of subgaleal hematomas include diffuse swelling of the head that may shift dependently when the infant’s head is reposi- tioned. This swelling indents easily on palpation and may be significant enough to result in hypovolemic shock. It is treated with a pressure bandage and replacement of volume if needed. Subgaleal hematoma is quite different than a cephalohematoma, which is a collection of blood that accumulates under the periosteum of a skull bone (usually the parietal) and is characteristically limited to the confines of the cranial bone. Intracranial hemorrhage (subdural, subarachnoid, intraventricular, and/or intraparenchymal hemorrhage) may also be life threatening. Signs of intracranial hemorrhage include convulsions, lethargy, obtundation, apnea, bulging fontanel, poor feeding, increased irritability, bradycardia, and/or shock.33 A vacuum assisted delivery is not an innocuous procedure and one should use vacuum only when indications and prerequisites exist. Proper application of vacuum is essential.

— Chapter H: Assisted Vaginal Delivery — 7 CONTRAINDICATIONS TO THE USE OF VACUUM 1. Prematurity — Use of vacuum extraction is generally considered inappropriate before 34 slide 27 weeks gestation, due to the risk of intraventricular hemorrhage.14 (Category C) However, two small retrospective case control studies demonstrated that the use of the silicone-rubber vacuum to assist vaginal delivery with mean fetal weights of 1,739 grams and 2,080 grams, did not appear to be associated with an increased risk of periventricular or intraventricular hemorrhage or other neonatal complications. The vast majority of these cases were performed for non-reassuring fetal heart tracings.33,34 Further studies with a prospective study design and larger sample sizes are warranted before the safe use of a silicone-rubber vacuum can be advocated in premature fetuses. 2. Breech, Face, Brow, or Transverse Lie. 3. Incomplete cervical dilatation — Exceptions to this are second twin vertex, small baby, and urgent delivery for non-reassuring fetal heart rate or hemorrhage. This should be done by experienced physicians only. 4. True cephalopelvic disproportion — In reality, this diagnosis is often made after a trial of vacuum has resulted in failure of delivery. One should use caution when applying vacuum to a macrosomic infant presenting at a higher station. 5. Head not engaged. 6. Delivery requiring excessive traction — Vacuum is self-limiting in the amount of traction.

POST-VACUUM CARE slide 28 Both mother and infant should be examined for evidence of birth trauma. Cases of neonatal scalp emphysema have occurred after vacuum extraction when the cup was applied over the scalp electrode site or if prior scalp sampling has been performed. The emphysema resolved within one week without complications. Localized caput formation or small cephalohematomas last from ten minutes to one week, usually disappearing within 24 to 48 hours after delivery. The infant should be watched closely for hyperbilirubinemia and subgaleal hematoma since there is a slightly higher incidence after vacuum extraction. If there is concern that scalp swelling may represent a subgaleal bleed then serial head circumference measurements and hematocrit are indicated. An operative note written or dictated in the chart is indicated. A sample operative note is included in Figure 1.

FIGURE 1. OPERATIVE NOTE AFTER INSTRUMENT DELIVERY slide 29 Preoperative Diagnosis — Prolonged second stage of labor with maternal exhaustion. Postoperative Diagnosis — Prolonged second stage of labor with maternal exhaustion. Vaginal delivery of a term male infant, birth weight eight pounds, six ounces, Apgar score nine and nine. Operation — Outlet Vacuum Extraction. History — 20-year-old primigravida at 39 and 4/7 weeks by reliable dates with early ultrasound admitted in spontaneous labor, membranes intact, no vaginal bleeding, stable vital signs. Prenatal risks – smoker. First Stage — 16 hours, 32 min. Spontaneous labor to complete cervical dilatation. AROM 6 hours prior to delivery, clear fluid. Analgesia with 100 micrograms of fentanyl times two. Second Stage — Two hours, 22 minutes. After two hours of pushing in the second stage, the patient was exhausted with stable vital signs. Fetal heart tones were reassuring (Category I) with intermittent

8 — — Chapter H: Assisted Vaginal Delivery Doppler auscultation per ACOG guidelines. Estimated fetal weight was 3800 grams. Vacuum extraction was offered to the patient and the father. The risks and benefits of vacuum delivery, including neonatal and maternal trauma, had been previously discussed in the office prior to delivery. Procedure — No regional anesthesia was used. The bladder was emptied with a straight catheter. On examination, the cervix was completely dilated and the position of the fetus was direct anterior, station +3. The vacuum cup was applied with the center of the cup over the flexion point and the edge of the cup over the posterior fontanel. A finger sweep ensured that no maternal tissue was trapped beneath the cup. Pressure was applied to ten units and again, a finger sweep ensured no trapped maternal tissue. During a contraction, pressure was elevated to 50 units and moderate traction in line with the pelvic axis was applied. With two pushes, delivery of an 8 lb, 6 oz. male infant occurred with apgars nine at one minute and nine at five minutes. No “popoffs” occurred. No episiotomy was necessary. Third stage — Ten minutes. Ten units of pitocin intermuscularly given after the anterior shoulder. The third stage was actively managed. Placenta was intact and spontaneous, cord three vessels, blood loss less than 500 cc, no maternal tears or trauma noted.

FORCEPS Simpson forceps consist of two interlocking parts, named “right” and “left” according to the side of the mother’s pelvis in which they lie when applied. Each forcep has a handle, a shank, a lock, and a blade. The distal end of the blade is called the toe, and the part nearest the shank is the heel of the blade. The blades are curved on the inner-medial side producing the cephalic curve conforming to the fetal head. The superior and inferior edges of the blades curve in such a way as to reproduce the pelvic curve, which fits in the hollow of the sacrum and conforms to the maternal pelvis.

For the beginner, the acronym ABCDEFGHIJ is again used: slide 30 A = A sk for help, Address the Patient, and is Anesthesia adequate? An epidural block or pudendal block are most effective; a local can be considered. B = B ladder empty? Make sure the bladder is not full as this may lead to dystocia and also may lead to bladder injury with an instrument delivery. If needed, perform a straight catheterization. C = C ervix must be completely dilated. slide 31 D = Determine position of the fetal head. Think of shoulder dystocia. E = Equipment ready (suction, cord clamp, instrument table etc.). F = F orceps ready. Many providers will coat the forcep blades with surgical soap for ease of application.

The two forceps blades should be articulated and held up to the vaginal introitus by the operator slide 32 in exactly the position and attitude that they will be in after they are applied. Then the blades are disarticulated and the left blade taken in the left hand. The left forceps blade is applied first under usual conditions. It is grasped in the left hand with a pencil grip and is applied to the left side of the mother’s pelvis, and also to the left side of the baby. The cephalic curve should be inward toward the vulva, and the shank vertical as you start the application.

The blade is applied to the left side of the fetal head (in occiput anterior positions) normally with two fingers of the right hand inserted deeply into the posterolateral aspect of the vagina to protect the maternal vaginal tissues and to guide the blade into position. The right thumb on the heel of the blade is used to apply the actual force of application of the left blade rather than the left hand on

— Chapter H: Assisted Vaginal Delivery — 9 the handle or shank of the forceps. In fact, the forceps blade slides almost effortlessly into place as the handle of the forceps drops down in a large arc laterally alongside the mother’s right leg.

The right forceps handle is then held in the right hand during insertion and is applied to the right side of the fetal head on the mother’s right with the left hand protecting the maternal right pelvis and guiding the blade into position. The locks should articulate if the blades are correctly applied. Depressing the handles slightly to bring the locks together is sometimes helpful.

The following are points to check the adequacy of the application: a. The posterior fontanel should be midway between the shanks and one centimeter above the plane of the shanks. This ensures the proper flexion of the head to present the narrowest diameter to the pelvis. If the posterior fontanel is higher than one centimeter above the plane of the shanks, then traction will cause extension of the head, present greater fetal diameters to the pelvis, and make the delivery more difficult. b. The fenestrations should be just barely palpable and admit no more than a fingertip. If more than a fingertip is felt, then the blades aren’t inserted far enough to be below the fetal malar eminence and will dig into the fetal cheeks causing potential injury. c. The lambdoidal sutures should be above and equidistant from the upper or superior surface of each blade. This assures the sagittal suture is in the midline in between the blades, where it should be to assure proper forceps application.

To summarize, make sure the forceps are applied correctly by thinking of “position for safety” slide 33 (“p”osterior fontanelle, “f”enestration, “s”utures: lambdoidal and sagittal).

G = G entle traction (Pajot’s maneuver). The birth canal curves through the pelvis from the inlet slide 34 through the outlet, and the curve is often described as an arc or a J-shape when viewed from a sagittal projection. For the operator during a forceps delivery, the curve starts in a downward direction, then sweeps in a large arc towards the operator, almost completing a 180-degree turn depending on the initial station of the head. The direction of traction on forceps blades should always be in the same axis as the pelvic curve for any given station of the head. This is the concept of axis traction.

Pajot’s maneuver consists of having one of the operator’s hands pulling on the forceps handles slide 35 in the same direction that the handles extend outward and away from the mother. The other hand should be placed on the shanks either from above or below and a downward pull exerted. Thus, there are two vectors of force, one roughly horizontal outward and one roughly vertical downward. These vectors summate to a direction of force, which is outward and downward. When the fetus is at a +3 station, this downward and outward force will be in the axis of traction and will bring the head down under the symphysis. Traction in this manner will complete the downward part of the pelvic curve. After the head has come down under the symphysis, the axis of traction begins to stem upward as the head begins to extend or stem up under the symphysis.

slide 36 H = Handle elevated to follow the “J” shaped pelvic curve. Ultimately, if the forceps are not removed before the delivery is complete, the shanks will be vertical, or even past vertical as the head extends up and out of the outlet.

10 — — Chapter H: Assisted Vaginal Delivery I = Evaluate for Incision, or episiotomy, when the perineum distends. Some physicians advocate episiotomy with operative deliveries. Simpson forceps have split shanks, which put more pressure on the perineum, but also allow the operator to cut an episiotomy through the split in the shanks.

J = Remove forceps when the Jaw is reachable. The forceps are removed in the reverse order of their application. The right blade is removed first by following the curve of the blade up and over the head anteriorly. Then the left blade is removed in a similar fashion. Removal may be accomplished before the head is completely out, to decrease tension on the perineum.

DELIVERY OF AN OCCIPUT POSTERIOR WITH FORCEPS The ALSO Provider Course does not teach forceps rotation. Forceps delivery of an occiput posterior, however, is possible. Forceps are applied in the usual manner. The mechanisms of labor are somewhat different with an OP position: extension will not occur and further flexion of the head is limited by the symphysis pubis. Therefore, horizontal traction is applied to the forceps until the top of the nose appears beneath the symphysis. Slow, upward motion then exposes the occiput, followed by downward pressure to deliver the face.

POST-FORCEPS CARE slide 37 After the infant is delivered, a thorough cervical and vaginal exam is essential to rule out lacerations. Providers should also be prepared for managing a postpartum hemorrhage.

The infant should be examined for evidence of birth trauma (fractured clavicle, cephalohematoma, lacerations-abrasions, facial nerve palsy, etc.). The infant often has visible “forceps marks.” These are benign, and usually disappear in a day or two. They should be inspected carefully, because they provide evidence of the accuracy of the application.

On the first postpartum day, the mother should be questioned about her perceptions of the need for forceps and how the delivery went. Any misconceptions she may have about the delivery should be addressed. A detailed written or dictated operative note should be completed, as for vacuum. slide 38 SUMMARY Although the incidence of assisted vaginal delivery continues to decline all providers offering labor and delivery care should be familiar with vacuum and/or forceps, including the indications, complications and how to properly document any operative vaginal procedure. Although vacuum and forceps use is safe in the majority of circumstances, there are associated risks of maternal and neonatal complications that must be considered. This chapter discussed the prerequisites to operative vaginal delivery, outlined standard definitions, and described the instruments and their accepted use.

SUMMARY TABLE OF RECOMMENDATIONS Category A Epidural anesthesia is associated with longer first and second stages of labor, an increased incidence of fetal malposition, use of oxytocin, and assisted vaginal deliveries.3 The continuous presence of a support person was associated with a slight reduction in the length of labor and reduced the likelihood of assisted vaginal delivery.5

— Chapter H: Assisted Vaginal Delivery — 11 The use of any upright or lateral position was associated with a reduction in the duration of second stage of labor, number of assisted deliveries and episiotomies, but a small increase in second- degree perineal tears.4 Operative vaginal delivery using a vacuum device can cause less maternal trauma than forceps, but it can increase the risk of neonatal cephalohematoma and retinal hemorrhage.15 No differences in outcome (time to delivery, method failure, maternal lacerations, episiotomy extension, incidence of cephalohematoma, and neonatal outcome) have been shown with intermittent reduction in vacuum pressure or attempts to prevent loss of station.28 The soft cups appear to be appropriate for uncomplicated deliveries needing assistance in the second stage. Rigid cups appear to be more suitable for occiput-posterior, asynclitism, occiput transverse, and difficult occiput anterior position deliveries.6

Category B Operative vaginal delivery using both a vacuum device and forceps has been associated with worse neonatal outcomes than using a single instrument.21,29,35

Category C When intervals for prolonged second stage are exceeded, an assisted delivery may be indicated but waiting longer is safe as long as progress is being made and the fetal status is reassuring.7,8 Vacuum extraction in pregnancies before 34 weeks is not recommended, until further study, because of the potential risk of intraventricular hemorrhage.14 Rocking movements or torque should not be applied to the vacuum device; only steady traction in the line of the birth canal should be used in order to avoid birth trauma to the neonate.28 With vacuum use, the operator should halt the procedure if disengagement of the cup occurs three times or there has been no progress in three consecutive pulls.29 Use of the vacuum extractor is suggested to not be for more than 20 minutes total application.30 The proportion of fetal injuries increases significantly between 11 to 20 minutes duration, compared to less than 10 minutes.30

Tribute This chapter is in honor of John Damos Sr. who died suddenly February 1, 1999, during my last ALSO Advisory Board meeting in San Antonio, Texas. It was John Damos, a small urban restaurant owner, who always had a free meal for the poor or a listening ear for the distraught, and my mother, Lorraine Damos, a compassionate nurse, who taught me the value of hard work, dedication, loyalty, and concern for the underprivileged. — James R. Damos, M.D.

12 — — Chapter H: Assisted Vaginal Delivery REFERENCES

1. Martin JA, Hamilton BE, Sutton PD, Ventura SJ, et 17. Johnson JH, Figuerosa R, Garry D, Elimian A, Maulik al. Births: Final data for 2006. National vital statistics D. Immediate maternal and neonatal effects of forceps reports; vol 57 no 7. Hyattsville, MD: National Center for and vacuum-assisted deliveries. Obstet Gynecol. Health Statistics. 2009. 2004;103(3): 513-8. 2. Powell J et al. Vacuum and forceps training in resi- 18. Y. Okunwobi-Smith, I. Cooke and I.Z. MacKenzie, dency: experience and self-reported competency. J Decision to delivery intervals for assisted vaginal vertex Perinatol 2007. 27(6): 343-6. delivery, BJOG 107 (2000), pp. 467–471. 3. Anim-Somuah M, Smyth RMD, Howell CJ. Epidural 19. Murphy DJ, Koh DK. Cohort study of the decision to versus non-epidural or no analgesia in labor. Cochrane delivery interval and neonatal outcome for emergency Database of Systematic Reviews 2005, Issue 4. operative vaginal delivery. Am J Obstet Gynecol 2007 4. Gupta JK, Hofmeyr GJ, Smyth RMD. Position in the Feb;196(2):145.e1-7. second stage of labor for women without epidural 20. Johanson RB, et al. Maternal and child health after anaesthesia. Cochrane Database of Systematic assisted vaginal delivery: five-year follow up of a Reviews 2004, Issue 1. randomized controlled study comparing forceps and 5. Hodnett ED, Gates S, Hofmeyr GJ, Sakala C. ventouse. Br J Obstet Gnaecol. 1999. 106(6): 544-549. Continuous support for women during childbirth. 21. Towner D, Castro MA, Eby-Wilkens E, Gilbert WM. Cochrane Database of Systematic Reviews 2007, Effect of mode of delivery in nulliparous women Issue 3. on neonatal intracranial injury. N Engl J Med 6. Saunders NJ, Spiby H, Gilbert L et al: Oxytocin infusion 1999;341:1709-1714. during second stage of labor in primiparous women 22. Bachman J. Forceps delivery [letter]. J Fam Pract using epidural analgesia: a randomized double blind 1989;29(4):360. placebo controlled trial, BMJ 299:1423-1426, 1989. 23. Vacca, Aldo, Handbook of Vacuum Delivery in 7. Cheng YM, Hopkins LM, Caughey AB. How long is too Obstetric Practice 2009, Vacca Research long: does a prolonged second stage of labor in nullip- 24. Bofill JA. Rust OA. Devidas M. Roberts WE. Morrison arous women affect maternal and neonatal outcomes? JC. Martin JN Jr. Neonatal cephalohematoma from 2004. 191(3): 933-938. Am J Obstet Gynecol. vacuum extraction. Journal of Reproductive Medicine. 8. Myles TD, Santolaya J. Maternal and neonatal out- Sept, 1997;42(9):565-9. (Level I) comes in patients with a prolonged second stage of 25. Boo NY, Foong KW, Mahdy ZA, Yong SC, Jaafar R. labor. Obstet Gynecol 2003. 102(1): 52-58. Risk factors associated with subaponeurotic haemor- 9. Johanson R, Menon V. Soft versus rigid vacuum rhage in full-term infants exposed to vacuum extrac- extractor cups for assisted vaginal delivery. Cochrane tion. BJOG. 2005;112(11):1516-1521. Database of Systematic Reviews 2000, Issue 2. 26. Sau A, Sau M, Ahmed H, Brown R. Vacuum extraction: 10. Warenski, JC. Managing difficult labor. Avoiding com- is there any need to improve the current training in the mon pitfalls. Clin Ob Gyn 1997;40(3):525-32. UK? Acta Obstet Gynecol Scand. 2004;83(5):466-470. 11. Impey, L and Boylan, P. Active management of labour 27. McQuivey RW. Vacuum-assisted delivery: a review. J revisited. Br J Ob Gyn March, 1999;106:183-187. Matern Fetal Neonatal Med. 2004;16(3):171-180. 12. Hansen SL, Clark SL, Foster JC. Active pushing 28. Bofill, JA, Rust OA, Schorr SJ, et. al. A randomized trial versus passive fetal descent in the second stage of of two vacuum extraction techniques. Obstet Gynecol labor: a randomized controlled trial. Obstet Gynecol. 1997;89:758-62. (Level I) 2002;99(1):29-34. 29. Murphy DJ, Liebling RE, Patel R, Verity L, Swingler R. 13 Cunningham FG, et al: Forceps delivery and vacuum Cohort study of operative delivery in the second stage extraction. In Cunningham FG, et al (eds): Williams of labour and standard of obstetric care. BJOG. 2003, Obstetrics, 22th ed. McGraw-Hill Companies, 2005 pp 110(6): 610-5. 547–563. 30. Teng FY. Sayre JW. Vacuum extraction: does duration 14. American College of Obstetricians and Gynecologists. predict scalp injury? Obstetrics & Gynecology. Feb, Operative vaginal delivery. Clinical management guide- 1997;89(2):281-5. lines for obstetrician-gynecologists Int J Gynaecol 31. Kudish B, Blackwell S, McNeeley SG, et al. Operative Obstet. 2001; 74(1): 69-76. vaginal delivery and midline episiotomy: a bad com- 15. Johanson RB, Menon V J. Vacuum extraction ver- bination for the perineum. Am J Obstet Gynecol. sus forceps for assisted vaginal delivery (Cochrane 2006;195(3):749-754. Review). In: The Cochrane Library, Issue 1, 1999. 32. Burlington, D.B. FDA Public Health Advisory: Need Oxford: Update Software. (Level I) for CAUTION When Using Vacuum Assisted Delivery 16. Angioli R, et al. Severe perineal lacerations during vagi- Devices, May 21, 1998. (Level III) nal delivery: the University of Miami experience. Am J Obstet Gynecol. 2000. 182(5): 1083-1085.

— Chapter H: Assisted Vaginal Delivery — 13 33. Thomas SJ. Morgan MA. Asrat T. Weeks JW. The risk of periventricular-intraventricular hemorrhage with vacuum extraction of neonates weighing 2000 grams or less. Journal of Perinatology. Jan.-Feb. 1997;17(1): 37-41. (Level II-2) 34. Morales R, Adair CD, Sanchez-Ramos L, Gaudier FL Vacuum extraction of preterm infants with birth weights of 1,500-2,499 grams. J Reprod Med. 1995 Feb;40(2):127-30. 35. Gardella C, Taylor M, Benedetti T, Hitti J, Critchlow C. The effect of sequential use of vacuum and forceps for assisted vaginal delivery on neonatal and maternal outcomes. Am J Obstet Gynecol. 2001;185(4):896-902.

The American Academy of Family Physicians would like to acknowledge: 1. Aldo Vacca, Vacca Research, and their CD-ROM entitled “Choices with Childbirth.” Many of this chapter’s illustrations were modeled after this CD-ROM. 2. Danforth’s Obstetrics and Gynecology, 8th Edition (Lippincott Williams & Wilkins). Some of this chapters illustrations were modeled after illustrations in Danforth.

14 — — Chapter H: Assisted Vaginal Delivery Chapter I Shoulder Dystocia slide 1 Robert Gobbo, MD Johanna Warren, MD Kim Hinshaw, MB, BS, FRCOG March 2012

slide 2 OBJECTIVES After completing this chapter, participants will be able to: 1. List the risk factors for shoulder dystocia. 2. Describe a systematic approach to managing a shoulder dystocia using the HELPERR mnemonic. 3. Demonstrate appropriate maneuvers to reduce a shoulder dystocia using a maternal-fetal mannequin. 4. Offer descriptions of management strategies and techniques that could be utilized by clinicians and birth attendants around the globe.

INTRODUCTION It is 2 AM, and your patient, a 22-year-old G1PO gestational diabetic with an estimated fetal weight of 3800 grams, has been in labor for what seems like an eternity. She has been pushing for two hours and is becoming exhausted. She tells you she can’t go on. You assess that the infant is at +3 station and offer her a vacuum assisted delivery. After consent, the vacuum cup is well applied and, despite one pop-off, the head subsequently delivers with her third assisted contraction. You are about to breathe a sigh of relief, but the head fails to restitute: the anterior shoulder does not deliver. An attempt to facilitate delivery of the anterior shoulder with gentle assistance is unsuccessful. The infant’s face and head are retracted against her perineum. The anterior shoulder is stuck, impeded by the pubic bone of the mother’s pelvis. You realize that you are dealing with a shoulder dystocia and the atmosphere in the room changes from one of excitement and anticipation to one filled with confusion, anxiety and fear. A focused calm approach to this obstetric emergency is needed. It is essential that you are able perform the maneuvers to free the impaction skillfully, and that you direct assisting caregivers’ efforts effectively. slides 3, 4 Definition and Etiologies Shoulder Dystocia (SD) is the failure to deliver the fetal shoulders(s) after the delivery of the head when attempts at gentle downward traction are unsuccessful. It may be preceded by the classic “turtle sign” (neonatal face and head retracted up against the maternal perineum). Attempts at stan- dardizing the definition of SD have included a head-to-body delivery time interval of greater than or equal to 60 seconds, or alternatively, the use of any ancillary maneuvers to affect delivery.1

Shoulder dystocia most commonly occurs when the bisacromial (breadth of the shoulders) diameter exceeds the diameter of the pelvic inlet.2 This typically results in a bony impaction of the anterior shoulder against the maternal symphysis pubis. Other mechanisms for SD can include a narrow maternal pelvis, persistent anterior-posterior orientation of the fetal shoulders due to increased resistance between the fetal body and vaginal walls, failure of the fetal trunk to rotate (as in cases of a precipitous or an assisted vaginal delivery), and impaction of the posterior fetal shoulder on the maternal-sacral promontory with the shoulders often in an oblique position.2

— Chapter I: Shoulder Dystocia — 1 Incidence The overall incidence of shoulder dystocia varies and ranges from 0.2 to 3.0 percent of all deliveries. The reported rate is influenced by both fetal weight and body configuration along with clinical sub- jectivity and clinician reporting behavior. Shoulder dystocia has been reported to occur in 0.3 to 1 percent of vaginal deliveries with an infant weight of 2500 to 4000 grams, increasing to five to seven percent of infants weighing 4000 to 4500 g, 14.3 percent for those 4500 to 4750 g. and 21.1 percent of those weighing 4750 to 5000 g.3, 4, 5 When shoulder dystocia is defined by head-to-body interval delivery times of more than 60 seconds, its reported incidence increases to ten percent with only 25 to 45 percent of these cases documented as a shoulder dystocia by the delivering practitioner.1 Despite the additional risks posed by the macrosomic fetus, over 50 percent of cases of shoulder dystocia occur in the normal birth weight fetus and are usually unanticipated.

RISK FACTORS (See Table 1) Antenatal slide 5 A number of antenatal and intrapartum factors have been associated with an increased incidence of shoulder dystocia. Antenatal factors identified include prior shoulder dystocia, gestational diabetes, maternal obesity, post-dates pregnancy, macrosomia, short stature, male fetal gender, and abnormal pelvic anatomy. Two recent retrospective cohort studies of women with a history of shoulder dystocia in a previous pregnancy demonstrate a 7.3 to 25 percent incidence of recurrence.6, 7

To create a prediction model for shoulder dystocia, a retrospective multivariate analysis was performed evaluating known risk factors for SD. One hundred consecutive cases of SD were matched with 100 non-SD controls. The three significant independent variables associated with shoulder dystocia were birth weight > 4000 grams, one-hour 50 g glucola > 140 mg/dL [7.8 mmol/L], and operative vaginal delivery.8

Macrosomia The overall incidence of fetal macrosomia is rising, and is associated with a four to six fold greater risk of shoulder dystocia than normal weight infants.9, 10 There is no consensus on the definition of non-diabetic macrosomia; it has been defined variably as infants with birth weights > 4000 grams, 4500 grams, or 5000 grams. The most widely adopted definition of macrosomia is an infant with birth weight > 4500 grams in a non-diabetic mother. The lack of a clear definition of macrosomia, the challenge of accurately predicting birth weight prior to delivery given the known inaccuracies of both clinician weight-estimation by physical exam as well as sonographic exam11, 12, 13 impacts antepartum management (see Prevention section below for management).14

Gestational Diabetes Gestational diabetes affects three to six percent of all pregnancies.15 Diabetes has been shown to increase the incidence of shoulder dystocia by up to 70 percent. Macrosomic infants of diabetic mothers have larger shoulder and extremity circumferences and higher percentages of body fat than their weight-matched non-diabetic controls and account for an increased number of shoulder dystocia deliveries and brachial plexus palsies.3 In a large retrospective cohort study of 36,241 singleton pregnancies stratified by the diagnosis of gestational diabetes, infants born to mothers with gestational diabetes and a birth weight > 4000 g were found to have a higher frequency of shoulder dystocia (10.5 percent vs. 1.6 percent, p < 0.001) and Erb’s palsy (2.6 percent vs. 0.2 percent, p < 0.001).16

2 — — Chapter I: Shoulder Dystocia A 2009 Cochrane review demonstrated that treatment of diabetes in pregnancy with either oral agents or insulin significantly reduced the risk of macrosomia when defined as birth weight > 4000 grams (one trial, 1030 infants, RR 0.46, 95% CI 0.34-0.63) or birth weight > 90th percentile (three trials, 223 infants, RR 0.55, 95% CI 0.30-0.9). When the isolated outcome of shoulder dystocia was evaluated, the intensive treatment of diabetes with dietary advice and insulin was shown to reduce the risk of SD. A 2009 systematic review and meta-analysis17 confirmed that treatment for gestational diabetes reduces the risk of shoulder dystocia (two trials, 1961 total infants, RR 0.40, 95% CI 0.21-0.75).18

It is commonly believed that induction of labor at term (versus expectant management) for suspected macrosomia in women with gestational diabetes may decrease actual birth weight, preventing escala- tion to > 90th percentile, and thereby decrease shoulder dystocias. A 2009 systematic review showed a significantly greater percentage of infants with birth weight > 90th percentile in the expectant management group (23 percent vs. 10 percent, p = 0.02), but no significant differences in rates of shoulder dystocia. More studies are needed to help guide our obstetric practices in this area.19

Intrapartum

Labor Although two earlier studies found no significant differences in active phase disorders in shoulder dystocia and control groups,20, 21 a large retrospective cohort study of women with term, singleton, cephalic gestations diagnosed with active phase arrest (no cervical change for two hours despite adequate uterine contractions) revealed that among women delivering vaginally, the adjusted odds ratio for shoulder dystocia was 2.37 (95% CI 1.33-4.25). Despite this increased odds ratio, however, there were no differences in neonatal outcomes of acidemia, NICU admission, sepsis, or Erb’s palsy.22 slide 6 Operative Vaginal Delivery Operative vaginal deliveries with either vacuum or forceps, and certainly with the sequential use of both instruments, carry a significant risk for subsequent shoulder dystocia and fetal neurologic injury.3, 23 The fetus is normally in a position of flexion and shoulder adduction while in the birth canal. One suggested mechanism for SD with operative vaginal deliveries surmises that as the instrument is placed on the fetal vertex and traction instituted, the vertex can be pulled away from the body causing the neck to elongate and the shoulder to abduct. This produces an increased bisacromial diameter and increases risk of shoulder entrapment by the maternal symphysis pubis.24 Vacuum and forceps deliveries increase the risk of a brachial plexus injury to odds ratio 2.7 (95% CI 2.4 to 3.1) and 3.4 (95% CI 2.7 to 4.3), respectively.25, 26

— Chapter I: Shoulder Dystocia — 3 Table 1. Risk Factors for Shoulder Dystocia Antenatal Risk Factors Labor Risk Factors

Prior delivery with a shoulder dystocia Assisted vaginal delivery with vacuum Gestational or preexisting diabetes or forcepts Macrosomia Labor dystocia/arrest disorders Male gender Prolonged second stage Maternal obestity Post-dates pregnancy Abnormal pelvic anatomy Short stature (< 5 ft or 1.5 m)

Currently, risk factor assessment is a relatively poor positive predictor for the occurrence of shoulder dystocia.27 Without reliable prediction models, it is a challenge for clinicians to counsel mothers on risks to themselves and their infants, and to make effective joint decisions regarding planned modes of delivery.

MORBIDITY AND MORTALITY Injuries to both the mother and infant can produce both serious short-term and long-term consequences. Prevention strategies and appropriate management and training can reduce these complications. slide 7

Soft tissue injuries are the most common maternal complication, with increased rates of third and fourth degree extensions or tears, and subsequent potential for recto-vaginal fistula formation. Postpartum hemorrhage due to uterine atony or birth canal trauma is also more common. Symphyseal diathesis and uterine rupture occur rarely, although symphyseal separation and transient femoral neuropathy have been associated with the McRobert’s maneuver.28

Neonatal Not all shoulder dystocia case series’ have comprehensively documented adverse neonatal outcomes, thus an exact incidence for fetal injury is difficult to determine. Brachial plexus palsies are among the most common and worrisome complications of shoulder dystocia and occur in seven slide 8 to 20 percent of infants whose deliveries were diagnosed with a shoulder dystocia.29 While nearly all infants recover within six to 12 months, one to two percent will be left with a permanent and disabling injury. Two types of nerve injury are generally described: Erb‘s palsy (more common) involving C5 to C6 nerve roots, and Klumpke’s Palsy involving C8 to T1 nerve roots. Clavicular and humeral fractures are additional potential injuries associated with shoulder dystocia, though simple fractures typically heal without deformity or complication.

There is a common perception in the medical-legal community that the clinician delivering the infant has a significant role in causing injury during a shoulder dystocia, via excessive traction and lateral extension exerted on the fetal neck during delivery. Stretching, tearing, or avulsing cervical nerve roots from the spinal cord are identified as potential mechanisms of injury. Simulation models suggest that rapid jerking or pulling movements are likely to cause significant stretch and injury to the brachial plexus and should be avoided.30, 31, 32

4 — — Chapter I: Shoulder Dystocia Although shoulder dystocia at the time of delivery is commonly blamed for brachial plexus palsies, it is now accepted that both in-utero positioning of the infant (with uterine anomalies such as a lower uterine segment fibroids or an intrauterine septum)33 and propulsive labor forces (including abnormal labor patterns of dilatation and descent) have been identified as causing brachial plexus palsies.27 Simulation-based studies evaluating mechanical fetal response during deliveries (with and without shoulder dystocias) have revealed the following: • The posterior brachial plexus experienced greatest stretch during descent for non-SD deliveries. • The anterior brachial plexus experienced similar quantified stretch among non-SD deliveries as well as deliveries with both a unilateral and bilateral SD simulation.34 • Force with clinician-applied maneuvers during a SD is reduced with use of standard maneuvers compared to continuing the delivery in the lithotomy position. • Delivery of the posterior arm correlated with the most significant reduction in delivery force and nerve stretch, but may be more difficult to perform than other maneuvers.35

A review of the medical literature and legal case law surrounding Obstetric Brachial Plexus Injury (OBPI) in the UK presented a template for reviewing the strength of evidence for OBPI in clinical negligence. This paper revealed evidence-based criteria predicting which cases of shoulder dystocia are more likely to be due to propulsive or labor forces and which are more likely due to iatrogenic causes (See Table 2).30 Other studies, however, have disputed the claim that anterior OBPI are purely iatrogenic in nature.

Table 2. Mechanisms of Injury in Obstetric Brachial Plexus Injuries

Propulsion Injury Iatrogenic Injury

Posterior arm injured Anterior arm injured No shoulder dystocia Shoulder dystocia Up-to-date training Lack of recent training Appropriate protocol followed and all Incorrect maneuvers/persistence with maneuvers correctly performed an ineffective maneuver No evidence of excess traction Evidence of excess traction Correct number of birth attendants Insufficient number of birth attendants Precipitous second stage Use of fundal pressure Temporary injury Permanent injury

Table adapted from: Draycott T, Sander s C, Crofts J and Lloyd J. A template for reviewing the strength of evidence for obstetric brachial plexus injury in clinical negligence claims Clinical Risk 2008; 14: 96–100.30

Birth asphyxia and neonatal encephalopathy due to prolonged delivery time are other potential neonatal injuries associated with shoulder dystocias. The time interval considered safe from the moment of the delivery of the fetal head to the resolution of the shoulder dystocia and ultimate delivery of the infant is not clear. Once the fetal head has delivered during a shoulder dystocia, umbilical cord compression between the fetal body and the maternal pelvis is a concern and could result in fetal hypoxemia, metabolic acidosis, and with significant delays in reduction of the impacted shoulder and delivery of the infant, permanent neurological damage or even death.36

— Chapter I: Shoulder Dystocia — 5 One investigator found that shoulder dystocia resulted in statistically significant, but clinically insignificant, reductions in mean umbilical artery blood gas parameters when compared with the mean arterial pH of all vaginal deliveries in their institution (7.23 G 0.082 vs. 7.27 G 0.069, P = 0.001). Surprisingly, among the group of 44 shoulder dystocia cases with recorded intervals, increasing head-to-body delivery interval (HBDI) was not correlated with a lower pH (P = 0.9), nor a higher pCO2 (P = 0.496), or base deficit (P = 0.618) nor did the time for shoulder dystocia resolution correlate with a lower five-minute Apgar scores.37 When comparing cases of shoulder dystocia stratified by the number of maneuvers (ranging from one to three), no significant differences in umbilical artery pH were found using pH thresholds of 7.10 and 7.00. Rates of cord pH < 7.20 were 25.6 percent, 28.6 percent, and 25 percent as the number of maneuvers required for delivery increased from one to three, respectively. Finally, cord pO2, pCO2, and base excess were also comparable between the groups.38

In the only study specifically evaluating neonatal brain injury as an outcome measure, Ouzounian found that brain injury cases were associated with significantly prolonged head-shoulder delivery intervals (10.6 +/- 3.0 minutes vs. 4.3 +/- 0.7 minutes, P = .03), and that a head-shoulder delivery interval threshold of seven minutes had a sensitivity and specificity of 67 percent and 74 percent, respectively, in predicting brain injury.39 Two recent studies revealed that the respective incidences of severe acidosis (pH < 7) and hypoxic ischemic encephalopathy with HBDI of < 5 minutes and ‡5 minutes were 0.5 and 0.5 versus 5.9 and 23.5 percent40 and that majority of neonates with depression (57 percent) had head-to-body delivery intervals greater than four minutes.41

During shoulder dystocia, it has empirically been believed that fetal acidemia results from umbilical cord compression, compression of the fetal neck resulting in cerebral venous obstruction, excessive vagal stimulation, and bradycardia may also contribute to severe clinical deterioration out of proportion to the duration of hypoxia.27

Given the lack of scientific data concerning the impact of shoulder dystocia upon the fetal pH, there is no clearly established point at which irreversible brain injury can be predicted. However, the important clinical point is that most impacted fetuses can tolerate a delay in delivery allow- slide 9 ing for maneuvers to be carried out in a calm, organized and safe manner. It is reasonable to assume that the risk of permanent central neurologic dysfunction may be associated with prolongation of the head-shoulder delivery interval greater than five to seven minutes. Once cord pH is less than 7.00, fetal brain asphyxia and neurological impairment will become more likely. In the vast majority cases of SD, this time interval should be more than adequate to deliver the infant utilizing the described maneuvers below, with rare exception.

PREVENTION There may be little that can be done to prevent a shoulder dystocia. Two Cochrane reviews42, 43 concluded that there is insufficient evidence regarding the beneficial effect of induced labor on shoulder dystocia prevention. Predicting a macrosomic fetus using standard ultrasound fetal biometry extrapolations in an uncomplicated pregnancy, is modest at best. Biometrically derived fetal birth weights vary by as much as seven to 15 percent between predicted and actual, not statistically better than an experienced clinician’s estimation by abdominal palpation44 and between 12 to 37 percent in another.25 Infants of diabetic mothers have more body fat distribution in the upper torso, they are considered at higher risk for shoulder dystocias, than infants of the same weight to non-diabetic

6 — — Chapter I: Shoulder Dystocia mother.44, 45 Fetal cheek-to-cheek diameters (CCD) and bisacromial diameters (BAD) offer slightly more accurate predictions of fetal weight and body fat composition and may assist in clinical decision making for pregnancies complicated by gestational diabetes,46 yet still are not commonly utilized.

Two retrospective cohort studies evaluated the fetal abdominal diameter (AD) and biparietal diameter (BPD) as markers of fetal asymmetry in the prediction of shoulder dystocia. One found that with an AD-BPD of > 2.6 cm, the risk of shoulder dystocia was 25 percent overall, and 38.5 percent in patients with diabetes.47 The second study revealed an adjusted OR of shoulder dystocia in the group with a sonographic AD-BPD difference > 2.6 cm of 3.67 (95% CI 1.44-9.36).48

With these current limitations in prediction accuracy, suspected macrosomia alone is not an indication for induction or primary cesarean delivery in uncomplicated pregnancies. There is insufficient evidence to establish a threshold of estimated fetal weight that would mandate cesarean delivery.44 Despite the lack of evidence, most clinicians in the US follow the American College of Obstetricians and Gynecologists (ACOG) acknowledgement that a planned cesarean delivery for shoulder dystocia prevention may be a reasonable management option in pregnancies with suspected fetal macrosomia when the estimated fetal weight is > 5000 g in a non-diabetic woman or > 4500 g in a woman with diabetes.49

However, the current literature provides no clear evidence regarding when to recommend the use of elective cesarean delivery for the prevention of shoulder dystocia in patients at risk. Analytic decision models have estimated that 3,695 elective cesarean deliveries would be needed to prevent one permanent brachial plexus injury among non-diabetic patients with an estimated fetal weight greater than 4500 grams.50 A policy of routine cesarean delivery for all infants with macrosomia would result in at least a five to six fold increase in cesarean rate in this group of patients. Spontaneous vaginal delivery should be expected for most babies who are estimated antenatally to be macrosomic, but anticipatory management during labor should be carefully organized. In patients with significant risk factors for SD, the risks and benefits of cesarean delivery should be discussed and considered.49, 51, 52

A cost-effectiveness analysis for deliveries of infants weighing greater than 4500 g found that expectant management (allowing the patient to go into labor) was determined to be the preferred strategy at a cost of $4,014 per injury-free child, compared with elective cesarean delivery at a cost of $5,212. However, with a shoulder dystocia permanent injury rate of ten percent, many clinicians and parents in developed countries with low rates of perinatal morbidity and mortality would not likely see this cost savings as reason enough to forego a cesarean delivery.53

The correlation between assisted vaginal deliveries and shoulder dystocia is well documented.3, 45, 54-55 The rate of shoulder dystocia is lower among women undergoing forceps (1.5 percent) than vacuum delivery (3.5 percent).56 As mentioned previously, the application of traction, increasing number of tractive efforts and duration of the vacuum attempt are strongly associated with brachial plexus palsy. While assisted vaginal deliveries are important techniques to aid patients’ deliveries with appropriate indications, the injudicious use of these instruments will place patient and their infants at risk for injury.57

— Chapter I: Shoulder Dystocia — 7 Using the combination of McRobert’s maneuver with suprapubic pressure as a prophylactic measure for preventing a shoulder dystocia in all deliveries was addressed by a recent Cochrane review.55 Although one of the evaluated studies did find a reduction in shoulder dystocia in the preventative treatment group (RR 0.44), a higher rate of cesarean deliveries in the treatment group could have skewed the data.58 In the second study, evaluating only the McRoberts’ maneuver, there was a statistically insignificant trend toward more therapeutic maneuvers for women who were in the control group (RR 0.31, 95 percent CI 0.09-1.02).58, 59 Although these results are intriguing, the sample sizes of the studies are sufficiently small so as to necessitate further studies to determine whether these interventions are effective.

MANAGEMENT Anticipation If antenatal or intrapartum risk factors suggest that a shoulder dystocia may be encountered, many tasks can be accomplished in advance of the delivery, through anticipation and preparation. Key personnel can be called prior to delivery and placed on alert. The patient and her family should be educated about the possibility of a potentially difficult delivery, and can be shown what they may be asked to do in that event. The patient’s bladder can be emptied and the room cleared of any unnecessary clutter, to make room for additional personnel and equipment. A bedpan should be available to raise the maternal pelvis if stirrups are not available.

Stopping to suction the oropharynx before the anterior shoulder has delivered is not required and may impede the natural process of descent, restitution and delivery.60 The amount and degree of gentle downward traction required to deliver the anterior shoulder has been studied in simulation slide 10 settings and is a frequent question among participants in the ALSO® workshop. Laboratory model- ing has shown that, for relatively small or normal shoulder dimensions, shoulder extraction can occur successfully when a force of about 45 to 60 N (5 kg or 12.5 lbs) is applied, whereas greater bisacromial dimensions require a traction force up to 100 N (9.8 kg or 25 lbs).61

Computer and simulation models have suggested that force in excess of 100 N can cause significant stretch to the fetal brachial plexus leading towards injury. Most simulation studies suggest that participants are more likely to exceed this threshold of force if they have not involved in recent training, are more senior in experience or (most importantly) persist with an initial attempt or technique rather than moving onto another maneuver.61, 62 It is therefore imperative that the clinician and team respond to the emergent situation, determine fetal shoulder orientation and maternal obstruction in a systematic yet thoughtful approach, and avoid the use of excessive force, tugging, jerking and fundal pressure. The goal is to deliver the shoulders and fetus with methodical care to avoid trauma and injury to the mother and fetus.

Developing an Institutional Plan A critical step in addressing the emergency management of shoulder dystocia is to insure that all hospital personnel who may be involved are familiar with their roles and responsibilities. An institutional plan can be designed to delineate health care providers’ individual roles, and hospital “drills” or simulations can be conducted to test and rehearse this plan with labor and delivery staff on a regular basis.

8 — — Chapter I: Shoulder Dystocia On-site Assistance Once shoulder dystocia is diagnosed, the presence of additional assistants in the delivery room is critical. One of nurses is to be assigned the duties of recording events, obtaining designated equipment and supplies, and notifying the clinician of time intervals. Documentation of the maneuvers used and the duration of each maneuver may be valuable to prompt the clinician to move on to other maneuvers, rather than persisting in one that is not proving effective. All remaining individuals involved should have clearly defined roles (see Appendix A63 for sample recording document).

Additional Back-up A pre-arranged plan should identify members of a team ready to respond to this emergency. This team may include a family physician, midwife or obstetrician, a pediatrician or neonatologist, one or two labor and delivery nurses to assist with maneuvers, and a nurse capable of caring for the newborn. At least one other provider with maternity or neonatal skills should be called immediately when a shoulder dystocia is encountered. In large centers, this may be a neonatologist, while at smaller hospitals, this may be a family physician, pediatrician or obstetrician. In some rural areas, this individual can be an emergency room physician or a physician partner who comes in from the office or home. Anesthesia staff should be called in order to administer medications as needed. A ward clerk or hospital operator should be available and prepared to assist in summoning appropriate individuals to the delivery room. This may involve developing a priority list of individuals to contact, and may be accomplished in part through a general overhead page such as “Code D: Labor and Delivery” or other appropriate notification that an obstetric emergency is underway.

Reduction Maneuvers and the “HELPERR” Mnemonic Shoulder dystocia becomes obvious after the head emerges and then retracts up against the perineum, commonly referred to as the “turtle sign.” Excessive force must not be applied to the fetal slides 11, 12 head or neck, and fundal pressure must be avoided. These activities are unlikely to free the impaction and may cause fetal and maternal injury while wasting valuable time. If standard levels of traction do not relieve the shoulder dystocia, the clinician must quickly move to alternate maneuvers to aid in delivery of the fetus. The family and nursing staff should be notified of the diagnosis and the staff asked to summon other personnel.

The clinician attending the delivery should direct the activities of the personnel in the room, in the same manner as if running a cardiopulmonary arrest code. It is important that other personnel listen to the directions being given and all act in a team-like fashion to address this emergency. An individual recording the events should keep time. Awareness of maneuver duration is essential, so that, if one maneuver is not successful after a reasonable amount of time, another maneuver can be attempted.

The “HELPERR” mnemonic can provide birth providers with a structured framework in which to deal with an extremely difficult and charged situation. Although there is no indication that any one of these techniques is superior to another, together they help clinicians take effective steps in relieving the impacted shoulder.27, 49, 51 The steps need not always be done in the same specified order as the mnemonic, although the initial steps up to and including suprapubic pressure are logically applied first as they are effective in the majority of cases and avoid initial internal manipulation. Recognize that if a maneuver is not working after an initial attempt (i.e., there is no further descent) or if the clinical situation warrants (i.e., an impacted posterior shoulder) it is acceptable to choose one step over another. It is more critical that the steps be employed efficiently and appropriately

— Chapter I: Shoulder Dystocia — 9 rather than in any particular order. Up to thirty seconds is recommended as the appropriate amount of time to spend on each maneuver. Although three to five minutes may seem like a brief window of time in which to act, it is will be adequate to conduct all of the maneuvers described in the HELPERR mnemonic.

Each of these maneuvers is designed to do one of three things: 1. Increase the functional size of the bony pelvis. 2. Decrease the bisacromial diameter (width of the presenting shoulders). 3. Change the relationship of the shoulders-bisacromial diameter within the bony pelvis.

Fundal pressure (placing hand on the top on the maternal fundus and pushing the fetus and uterus towards the vagina) should be avoided. This simply duplicates a directional expulsive force that has already failed to deliver the fetal shoulders and serves only to further impact the anterior shoulder behind the symphysis pubis.27 There may also be a risk of uterine rupture. Many advocate that beside fundal pressure being prohibited in deliveries complicated by shoulder dystocia; documentation after the delivery should also clearly state that no fundal pressure was used in the delivery.

There is no clinical evidence elevating any one maneuver as superior over another in releasing the impacted shoulder or reducing the chance of injury.49, 64 Persistence in using only one ineffective or difficult maneuver has been associated with an increased incidence of brachial plexus palsy.65

H – Call for Help This step refers to activating the pre-arranged plan for personnel to respond with necessary equipment to the labor and delivery unit. If such a pre-arranged plan has not yet been developed, the slide 13 appropriate equipment and personnel should be requested, including someone to assist in neonatal resuscitation, and anesthesia personnel to assure that appropriate medications will be immediately available. As different people enter the room, each should understand and be given a defined role. Extraneous people present in the delivery room can increase the confusion and anxiety for the patient and staff.

E – Evaluate for Episiotomy Episiotomy should be considered, yet is not required in the management of shoulder dystocia. Shoulder dystocia is a bony impaction, so simply performing an episiotomy will not cause the shoul- slide 14 der to release. Since the majority of cases of shoulder dystocia can be relieved with McRobert’s maneuver and suprapubic pressure, many women can be spared a surgical incision unless it becomes necessary to make room for the clinician‘s hand in the vagina to perform internal maneuvers. However, do note that an episiotomy is very difficult to perform when the fetal head is tight against the perineum so clinical judgment may dictate performing an episiotomy before delivery if shoulder dystocia is strongly anticipated, as in a primiparous patient with a narrow vaginal four- chette and a infant with suspected macrosomia. Therefore we recommend that the clinician evaluate for an episiotomy in cases such as these.

10 — — Chapter I: Shoulder Dystocia Support for avoiding episiotomies for shoulder dystocia comes from a prospective cohort study of primiparous women undergoing an assisted vaginal delivery by forceps or vacuum of a singleton, cephalic, term fetus.66 Women receiving an episiotomy had a shoulder dystocia rate of 3.5 percent; women without an episiotomy had a rate of 1.7 percent. The adjusted OR was 1.42 (CI 0.53-3.85) and was not statistically significant. Furthermore, management by episiotomy or proctoepisotomy has been associated with a nearly seven-fold increase in perineal trauma without benefit in neonatal outcomes.67

L – Legs (McRoberts Maneuver) The simplicity of McRobert’s maneuver, and its proven effectiveness, make it an ideal first step in slides 15, 16 management. The maneuver requires flexing the maternal hips beyond 90 degrees, with abduction and external rotation to a position alongside the maternal abdomen. This simulates the squatting position, with the advantage of increasing the inlet diameter. Nurses and family members present at the delivery can provide assistance for this maneuver. When anticipated, it is helpful to demonstrate this to family members in advance. McRobert’s maneuver also straightens the lumbosacral lordosis, flattening the sacral promontory. This procedure simultaneously flexes the fetal spine, often pushing the posterior shoulder over the sacral promontory and allowing it to fall into the hollow of the sacrum. When this occurs, the maternal symphysis may rotate over the impacted shoulder. Finally, the direction of maternal force in this position is perpendicular to the plane of the inlet. When this maneuver is successful, normal traction should deliver the fetus. Delivery should be attempted in this position for approximately 30, seconds. McRobert’s maneuver alone is believed to relieve more than 40 percent of all shoulder dystocias. Combined with suprapubic pressure and/or episiotomy, over 50 percent of dystocias can be delivered.68, 69

P – Suprapubic Pressure An assistant should attempt external manual suprapubic pressure for no longer than 30 seconds slide 17 while the delivering clinician continues gentle traction. The suprapubic hand should be placed over the fetus’ anterior shoulder, applying pressure in a firm constant manner or in a “CPR” style in such a way that the shoulder will adduct or collapse anteriorly and pass under the symphysis. The pressure should be applied from the side of the mother that will allow the heel of the assistant’s hand to move in a downward and lateral motion on the posterior aspect of the fetal shoulder. The delivering clinician should direct the assistant as to the correct direction and to the effectiveness of the effort. Initially, the pressure can be continuous, but if delivery is not accomplished, a rocking or “CPR” motion is recommended to dislodge the shoulder from behind the pubic symphysis. If this procedure fails after 30 seconds, the next procedure should be immediately attempted. Fundal pressure is never appropriate and only serves to worsen the impaction, potentially injuring the fetus and/or mother.

Introduction to the Internal Maneuvers: A) Rotatory: Rubin, Woods, Reverse Woods and B) Removal of the posterior arm. All of these internal maneuvers are perfectly acceptable and clinicians should use the maneuver that they are most comfortable or familiar with. However, there is some controversy among practitioners and within the literature as to which maneuvers are most effective. There is some evidence to suggest that removal of the posterior arm as the initial internal maneuver is more successful at reducing the degree of brachial plexus stretch, and potentially being less traumatic to the fetus.70 A suggested algorithm is offered below.

— Chapter I: Shoulder Dystocia — 11 Shoulder Dystocia Management Algorithm: HELPERR slide 18

Call for HELP

Evaluate for Episiotomy

Legs (into McRobert’s position)

Add Suprapubic Pressure

Enter – internal rotatory maneuvers Remove posterior arm

Roll onto all fours (‘Gaskin’ maneuver)

Secondary Maneuvers a) Second attempt of initial maneuvers b) Rescue maneuvers (posterior axillary sling, symphysiotomy, Zavanelli, abdominal rescue)

E – Enter – Internal Rotary Maneuvers slide 19 These maneuvers attempt to manipulate the fetus in order to rotate the anterior shoulder into an oblique plane under the maternal symphysis. This can be accomplished with either the Rubin or Woods’ Screw maneuver. Several studies found that about one-third of patients required more than two internal maneuvers. These maneuvers are often the most difficult to understand and can lead to some confusion, yet with practice in the workstations, can be learned effectively. Gaining access for these maneuvers is best achieved by utilizing a posterior approach making use of the space in the sacral hollow. This will allow the clinician to perform internal maneuvers using two fingers or, in some cases, the whole hand.

12 — — Chapter I: Shoulder Dystocia There has been some discussion about whether having the eponyms included in the instruction of these maneuver’s is necessary.71 Historically, while the authors would like to acknowledge the clinicians credited with popularizing these techniques, it is more important that the learner understand the technique and directions required to relieve the dystocia and document them accurately.

1. Alan Rubin, in 1964, described two maneuvers, now sometimes called Rubin’s maneuver I and II. The first maneuver (Rubin I) is to rock the fetus‘ shoulders from side to side once slide 20 or twice by pushing on the mother’s lower abdomen just above her pubic bone. This is the PRESSURE component of the ALSO HELPERR mnemonic. The Rubin II maneuver consists of inserting the first two fingers of one hand vaginally behind the anterior fetal shoulder and pushing the shoulder anteriorly toward the fetal chest. Since there is often little room to insert a hand directly behind the impacted anterior shoulder, we recommend having the clinician insert his/ her hand behind the posterior shoulder where there is more space. Once the hand is inside the birth canal, it is slid over the fetal back to the anterior shoulder and pressure is applied.

Images courtesy of Kim Hinshaw, MD

Rubin had made the point that this pressure will adduct, or collapse, the fetal shoulder girdle, reducing its diameter. The ALSO-recommended method refers to pressure behind the anterior shoulder as in the Rubin II and can also be termed the “Anterior Rubin”, and is the basis for the first part of the ENTER component of the HELPERR mnemonic. McRobert’s maneuver can still be applied during this maneuver and may help facilitate its success.

— Chapter I: Shoulder Dystocia — 13 2. If Rubin 11 is unsuccessful, the Woods’ Screw maneuver can be combined with the Rubin II slide 21 maneuver. The Woods’ screw maneuver was first described by Dr. C. E. Woods in 1943, this maneuver calls for the provider to use the opposite hand to approach the posterior shoulder from the front of the fetus, and rotate the shoulder toward the symphysis in the same direction as with the Rubin II maneuver.72 Thus, in this combination, the provider has two fingers behind the anterior shoulder, and two fingers of the other hand in front of the posterior shoulder. The Rubin II maneuver collapses or flexes either the anterior or posterior shoulder while the Woods’ screw maneuver abducts or opens the posterior shoulder. This is why the combination of the two maneuvers may be more successful than the Woods’ Screw alone. With this movement, the infant’s shoulders rotate and deliver much like the turning of a threaded screw. The Woods’ Screw maneuver can require a large episiotomy or proctoepisiotomy to provide room for posterior manipulation, while the Rubin II maneuver generally does not.73 3. If the Rubin or Woods’ maneuvers fail, the Reverse Woods’ Screw or also called the slides 22, 23, 24 Posterior Rubin maneuver may be tried.

The fingers of the hand that had been on the front aspect of the posterior shoulder during the Wood’s screw maneuver should be removed from within the vagina. The fingers of the opposite hand, which have been on the posterior aspect of the anterior shoulder, are slid down to lie behind the scapula posterior shoulder. Once placed on the posterior shoulder from behind, the attempt is to rotate the fetus in the opposite direction as the Woods’ Screw maneuver. This rotates the fetal shoulders out of the impacted position and into an oblique plane from which they can deliver.

Images courtesy of Kim Hinshaw, MD

14 — — Chapter I: Shoulder Dystocia Much confusion has occurred regarding these maneuvers, (view the accompanying video) and even leading obstetrical texts have described them differently.74 These maneuvers can be very difficult to perform, particularly when the anterior shoulder is partially wedged underneath the symphysis. At times it is necessary to push the posterior shoulder, or sometimes the anterior shoulder, back up into the pelvis slightly in order to accomplish them.

Some investigators have experimented with mechanical simulation models in an attempt to quantify the degree of fetal neck rotation, brachial plexus stretch and the amount of force required to accomplish a difficult delivery. In laboratory models of initial maneuvers for shoulder dystocia, anterior Rubin’s (II) maneuver required the least traction for delivery and produced the least amount of brachial plexus tension. Both Rubin II and the Posterior Woods maneuvers (applying pressure on the posterior aspect of either the anterior or posterior shoulder) were found to require less traction force than McRobert’s (P < .0001), and brachial plexus extension was significantly lower after anterior Rubin’s maneuver compared with McRobert’s or posterior Rubin’s maneuvers.59 Further study is needed to validate these results in the clinical setting, yet these results underscore the importance of avoiding excessive traction forces on the fetal neck, and that maneuvers that focus on rotating the fetal body core seem to cause less stretch on the brachial plexus. slides 24, 26 R – Remove the Posterior Arm In this maneuver, the posterior arm is removed from the birth canal, thus narrowing the bisacromial diameter, resulting in a 20 percent reduction in shoulder diameter.74 This allows the anterior shoulder to ‘collapse’ as the fetus drops into the pelvic hollow, freeing the impaction anteriorly. In order to affect this maneuver, the clinician must insert his or her hand far into the vagina and attempt to locate the posterior arm.

If the baby’s back is towards the maternal right, the operator inserts his or her right hand into the vagina in front of the baby’s chest. The clinician’s hand must be lubricated and made small to aid insertion of the whole hand into the posterior vagina. Croft et al (2008) explained this by describing how a hand might be inserted into a “Pringle crisp can” - see slide and photo.75 Once in the vagina, the forearm is located and the delivering clinician applies pressure at the infant’s antecubital fossa in order to flex the forearm. The arm is then grasped at the wrists or forearm and delivered by a sweeping motion over the anterior chest wall of the fetus, then out over the fetal face. Rotation of the fetal trunk to bring the posterior arm anteriorly is sometimes necessary. The fetal upper arm should never be grasped and pulled directly, as this may fracture the humerus. If done correctly, first the posterior hand, then arm and finally shoulder will be removed, facilitating delivery of the infant. Often, the fetus rotates in a corkscrew manner as the arm is removed. The anterior shoulder will then rotate backwards under the symphysis and deliver.

— Chapter I: Shoulder Dystocia — 15 A difficult scenario is sometimes encountered when the arm is located behind the fetus’ back. The clinician should suspect this if upon entering the vagina, the posterior arm cannot be found in front of the fetal trunk, If this is encountered, the clinician should remove the hand that is in front of the fetal chest and insert the opposite hand behind the fetus’ back. Once the arm is located, it can be displaced under the fetal body and ‘nudged’ anteriorly to lie in front of the fetal chest. The clinician then removes his/her hand from behind the fetal back, and re-inserts the opposite hand into the birth canal in front of the fetal chest where the arm can now be located. The maneuvers described in the previous paragraph can then be followed. It is not unusual for a large episiotomy to be cut in order to accommodate the operator’s hands during these maneuvers, and 3rd and 4th degree extensions are not uncommon.

An elegant 2010 paper confirmed that all maneuvers do reduce the degree of force and resultant brachial plexus stretch required to achieve delivery. The greatest effect seen was with delivery of the posterior arm, which showed a 71 percent decrease in nerve stretch and an 80 percent reduction in force.76 A 2011 paper also noted that when all maneuvers were evaluated in cases of shoulder dystocia, removal of the posterior arm was associated with the highest success rate at delivering the infant, while not increasing the rate of injury.77 When examining the number of deliveries that included the different maneuver types, irrespective of order, 84.4 percent of deliveries had successful resolution of the shoulder dystocia when delivery of the posterior shoulder was attempted. This was higher than the other maneuvers, which ranged from 24.3 percent (McRoberts) to 72.0 percent (Woods corkscrew).77

In order to affect this maneuver, the clinician must insert his or her hand far into the vagina and attempt to locate the posterior arm. Sometimes the arm is displaced behind the fetus and must be nudged anteriorly. Once the forearm is located, the elbow should be flexed so that the forearm may be delivered in a sweeping motion over the anterior chest wall of the fetus. The fetal upper arm should never be grasped and pulled directly, as this may fracture the humerus. If done correctly, first the posterior hand, then arm and finally shoulder will be reduced, facilitating delivery of the infant. Often, the fetus rotates in a corkscrew manner as the arm is removed. The anterior shoulder will then rotate backwards under the symphysis and deliver.

R R – oll the Patient slide 27 The “all fours” or “Gaskin” maneuver is a safe, rapid and effective technique for the reduction of shoulder dystocia. Ms.Gaskin is a renowned direct entry midwife in the U.S, best known for her book Spiritual Midwifery. The maneuver requires the patient to roll from the existing supine or dorsal lithotomy position to an all-fours position. The precise mechanism by which this maneuver acts to relieve the shoulder dystocia is unknown although it has been documented that the pelvic diameters increase when laboring women change from the dorsal recumbent position.78

Radiographic studies indicate that pelvic measurements are least favorable for delivery in the dorsal lithotomy position. By rotating to the all fours position, the true obstetrical conjugate increases by as much as 10 mm and the sagittal measurement of the pelvic outlet increases up to 20 mm.79 The fetal shoulder often dislodges during the act of turning from a supine to “all fours” position, indicating that this movement alone may be sufficient to allow enough pelvic change to dislodge the impaction. Additionally, once the position change is completed, gravitational forces may aid in disimpaction of the fetal shoulder.

16 — — Chapter I: Shoulder Dystocia The “all fours” maneuver may be difficult for a woman who is fatigued or restricted by intravenous lines, fetal monitors, epidural anesthesia or a Foley catheter. The patient will often need assistance to re-position, given these entrapments. At one facility, all patients with epidural anesthesia are instructed to perform a shoulder dystocia drill and practice getting into the all-fours position, in case it is needed later.80, 81 Consideration should be given to including this as part of prenatal education. This position may be disorienting to clinicians who are unfamiliar attending a delivery in this position, however by providing gentle traction downward, the clinician can deliver the posterior shoulder first with the aid of gravity in the same direction as if the patient was in the dorsal lithotomy position. The all-fours position is compatible with all intra-vaginal manipulations for shoulder dystocia, but it is incompatible with suprapubic pressure. A tip to remember is to always go with gravity first, thus provide gentle traction downward to deliver the shoulder closest to the ceiling first, (in this case the infant’s posterior rather than the anterior shoulder). Performing a few “normal” or simulated deliveries in this position, before encountering an acute need to do so, may assist the provider in being prepared for more emergent situations.

The order in which these maneuvers are attempted may be flexible. However, a logical progression of various efforts is essential to allow adequate time for each one to potentially accomplish delivery. The suggested length of time for each maneuver is meant only as a guideline. Clinical judgment should always guide the progression of procedures used. slide 28 Second attempt at all the maneuvers described above can be tried again; sometimes there has been some change in the position or station of the shoulder and a repeat attempt can be successful. If the second attempt is unsuccessful, the following techniques have been described as “last resort” or “salvage” maneuvers. slide 29 Sling: posterior axillary traction — The technique to deliver the posterior arm has been described in case series two different ways.82, 83 It may prove helpful in cases of SD when the sacral promontory holds up the posterior shoulder and all other maneuvers have failed.

The first variation is for the clinician’s hand to enter the birth canal along the sacral hollow and deliver the posterior shoulder before delivering the posterior arm. To make access easier to the posterior pelvis, an assistant holds (not pulls) the fetus’s head flexed upward toward the anterior shoulder. An episiotomy is helpful if the perineum is too rigid to allow entry. The birth clinician will need to get on one knee below the mother’s perineum in order to employ the correct downward vector. The right middle finger is placed into the fetus’s posterior axilla from the left side of the pelvis and the left middle finger is placed into the axilla that lies posteriorly. By using the two middle fingers in the axilla, traction is employed following the curve of the sacrum. Once the shoulder has emerged from the pelvis, the posterior arm can be delivered. At other times, the shoulder may not actually be delivered first but instead is brought down low enough in the pelvis that the posterior arm can be grasped and brought out.82

Another version of the posterior sling involves the use of a 14 Fr soft, plastic suction catheter and has been described in cases of severe shoulder dystocias that have persisted so long that the infant has died but is still undelivered. This technique has been noted to avoid having to put a mother through a symphysiotomy to accomplish the delivery. If the previously mentioned maneuvers are unsuccessful, the clinician uses the suction catheter to create a sling through the axilla of the

— Chapter I: Shoulder Dystocia — 17 infant’s posterior shoulder. The clinician folds the catheter in half over the operator’s right index fingertip and manually inserts the loop around the posterior shoulder and under the axilla. The loop is then retrieved with the left index finger and withdrawn so that the proximal end and tip of the catheter meet to create a sling around the shoulder.83 A hemostat or curved clamp can be applied to the ends of the sling and traction is applied in a posterior downward vector.

These techniques have their drawbacks. Fracture of the fetus’s posterior humerus is frequent. For the mother, tears of the anal sphincter and rectum will commonly occur due to the posterior pressure. Posterior axillary traction is by no means an original technique and has been described in at least two publications in the past,84, 85 but it does not seem to have been popularized. Success of this technique, however, presupposes that the posterior shoulder is accessible and is not held up by the sacral promontory. If the anterior shoulder is impacted by the symphysis pubis and the posterior shoulder is above the sacral promontory—in other words, if neither shoulder is in the pelvis—only cephalic replacement or symphysiotomy is likely to resolve the problem.

The Zavanelli Maneuver slide 30 The Zavanelli maneuver requires reversal of the cardinal movements of labor: derestitution (internal rotation), flexion, and subsequent manual replacement of the fetal vertex into the vaginal canal, followed by cesarean delivery.27, 86 Continuous upward pressure is then maintained on the fetal head until cesarean delivery can be accomplished. Induction of uterine relaxation with IV or SQ terbutaline or nitroglycerin administered by the oral, sublingual or IV route is valuable adjunct to this procedure, and potentially will prevent a uterine rupture. Alternatively musculoskeletal or uterine relaxation can be induced with halothane or other general anesthetic. Before considering cephalic replacement, an operating team, anesthesia, and physicians capable of performing a cesarean delivery must be present. This maneuver should never be attempted if a nuchal cord has been previously clamped and cut.

Surgery and Symphysiotomy 1. Symphysiotomy Intentional division of the fibrous cartilage of the symphysis pubis under local anesthesia has been used successfully in developing countries more than in North America and Europe. Reports in the U.S. are related to its use after failed Zavanelli maneuvers.87 Because the procedure takes at least two minutes from the time a decision is made, if needed, it should be initiated within five to six minutes of delivery of the fetal head and should only be used when all other maneuvers have failed and cesarean delivery capability is not available.88, 89 Some women with this procedure might encounter chronic symphyseal pain due to separation and could potential encounter urethral trauma. Global ALSO includes an optional symphysiotomy workshop (www.aafp.org/also). 2. Abdominal Surgery and Hysterotomy This technique has been reported to facilitate vaginal delivery of the fetus in a case of shoulder dystocia unresponsive to the above noted maneuvers. In a small series of case reports of severe shoulder dystocia, general anesthesia was induced and the uterus opened as similar to a cesarean section. The surgeon would then rotate the infant transabdominally through the hysterotomy incision, allowing the shoulders to rotate, much like a Woods Screw maneuver. Delivery is then accomplished by vaginal extraction by another clinician.90

18 — — Chapter I: Shoulder Dystocia 3. Deliberate Clavicular Fracture and Cleidotomy Direct upward pressure on the mid-portion of the fetal clavicle will result in fracture and reduce the shoulder-to-shoulder distance. Older textbooks have described this technique, however this has not been reported in recent literature because it is technically difficult to perform and risks serious injury to the underlying vascular and pulmonary structures in the newborn.27 However, formal cleidotomy (surgical division of one or both clavicles with heavy surgical scissors) can be considered in cases of shoulder dystocia when the fetus is dead and standard management techniques have failed. Obviously, there is a potential for maternal trauma unless great care is taken with this procedure.

DOCUMENTATION slide 31 Documentation in the medical records after a completed delivery is an essential risk management tool and several studies point to the lack of standardization and compliance in this matter. The use of a comprehensive, standardized procedure note in cases of shoulder dystocia has been advocated by many.91, 92

It is important to record the elapsed time of the shoulder dystocia, the maneuvers employed and the condition of the mother and infant after the delivery.93 Terms like mild, moderate, or severe shoulder dystocia offer little information about the maternity care that was provided or future legal issues. The documentation should also include other team members present and umbilical cord venous and arterial cord pH, if obtained. In case of subsequent nerve palsy develops, it is worthwhile to document which arm was impacted against the pubis and on which arm maneuvers were performed for removal. Please see appendix A.63

A retrospective observational study in the UK compared documentation of SD under three institutional documentation conditions; non-standardized, written delivery notes; standardized delivery notes after electronic medical record implementation; and standardized delivery notes in the electronic medical record following SD simulation drills. Standardized electronic notes improved documentation, but further addition of SD drills further increased SD documentation.94

SIMULATION TRAINING AND INSTITUTIONAL PLANS Simulation training and repeated practice of emergency drills has been demonstrated to improve performance in the management of simulated obstetrical emergencies, including shoulder dystocia. Simulation has evolved to include complex, high fidelity models - yet low-fidelity models can still be quite valuable, especially for the purpose of team training.

The SaFE study in Great Britain documented that a standardized training program with simulated deliveries involving 450 participants, resulted an increase in successful delivery rate and reduction in force amplitudes administered by clinicians.70

High-fidelity training pelvises (models with electronic and computer circuitry such as the Noelle™) have been shown to improve clinicians’ ability to use minimum traction force and a reduction in the actual incidence of neonatal injury. However, low fidelity (models used in the ALSO course—such as Simulaids™) models can provide the communication and team skills needed to successfully manage a shoulder dystocia delivery and limit psychological and medico-legal problems. Training

— Chapter I: Shoulder Dystocia — 19 programs should consider the inclusion of patient–actors with mannequins to increase the fidelity of simulation exercises. Further studies evaluating the effectiveness of ALSO training and ways of measuring traction forces with low fidelity models are needed to document course effectiveness in providing clinicians with improved shoulder dystocia management skills.62, 94-98

SUMMARY slide 32 Shoulder dystocia is a relatively uncommon and dangerous event, yet it is difficult to predict and 50 percent of shoulder dystocias have no antecedent factors. Anticipation and preparation are key to successful management.

An institutional plan is highly recommended, in which each member of the team has an assigned duty. The recommended management of shoulder dystocia is based on the mnemonic HELPERR, which provides a memory guide and a structured framework for action, which is useful in this crisis. The elements of the HELPERR mnemonic are all effective, and they should be tried in a logical and calm sequence. Practice on the mannequin is an essential aid to clinicians who are likely to encounter this obstetric emergency. The time allotted to each maneuver, and the exact sequence, are best determined by the clinical circumstances and the clinician’s best judgment, yet incorporat- ing suggested guidelines.

SUMMARY TABLE OF RECOMMENDATIONS Category A Routine late pregnancy ultrasound to detect macrosomia in low risk or unselected populations does not confer benefit by allowing reduction in morbidity from shoulder dystocia,42,44,47,48 and there is not enough evidence to evaluate the prediction of SD based on fetal size through fundal height, palpation, or ultrasound.1, 3, 42-45

Category B Induction of labor in non-diabetic women with suspected macrosomic infants does not prevent shoulder dystocia.3, 43, 44, 49

Suspected macrosomia is not an indication for induction or primary cesarean delivery in uncomplicated non-diabetic pregnancies unless estimated fetal weight is > 5000 grams.42-45

Shoulder dystocia is associated with instrumented vaginal delivery3, 25, 54, 57 and vacuum extractor use in excess of 10 minutes or more than five tractive efforts should be conducted with caution, as it is a prominent risk factor for neonatal brachial plexus palsy (BPP).57

Episiotomy performed at the time on an assisted delivery does not reduce the incidence of shoulder dystocia.66, 67

Simulation training, with both low and high fidelity models, has demonstrated benefit at improving clinicians’ skill levels, reducing force required to achieve a simulated SD delivery. In the clinical setting, simulation training has been shown to reduce the incidence of brachial plexus palsy where it has been required.62, 94-98

20 — — Chapter I: Shoulder Dystocia Category C An institutional plan for anticipating and managing shoulder dystocias is recommended, in which each member of the team has an assigned duty. The elements of the HELPERR mnemonic are effective. They should be instituted in a logical and calm sequence.73 Half of shoulder dystocias can be relieved by McRoberts maneuver and suprapubic pressure27, 68 and these noninvasive maneuvers are recommended for initial management. Rotary maneuvers and removal of the posterior arm have demonstrated less tractive force and stretch in simulation and computer animated models.61, 62, 70, 76, 94-98 The use of a comprehensive, standardized procedure note in cases of shoulder dystocia is strongly recommended.91-94

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Bruner J, et al. All fours maneuver for reducing shoul- 1989;74:44–8. der dystocia during labor. Journal of Reproductive 62. Crofts JF, Ellis D, James M, et al. Pattern and degree of Medicine; 1998;43;5:439-442. (Level III) forces applied during simulation of shoulder dystocia. 79. Borell U and Fendstrom I. A pelvimetric method for Am J Obstet Gynecol 2007;197:156.e1-156.e6. the assessment of pelvic mold ability. Acta Radiol 63. Shoulder Dystocia Documentation – Personal 1957a;47:365-370. (Level III) Communication with T. Draycott, 2011. 80. Meenan AL, Gaskin IM, Hunt P, et al. A new (old) 64. Gurewitsch ED, Kim EJ, Yang JH, et al. Comparing maneuver for the management of shoulder dystocia. McRoberts’ and Rubin’s maneuvers for initial manage- J Fam Pract 1991;32;625-629. (Level III) ment of shoulder dystocia: an objective evaluation. 81. Bruner JP, Drummond SB, Meenan AL, Gaskin IM. Am J Obstet Gynecol. 2005;192:153-160. Erratum in: Al fours maneuver for reducing shoulder dystocia Am J Obstet Gynecol. 2005;192:662. [LOE 3, other during labor. J Reprod Med 1998;43:439-43. disease-oriented evidence] 82. Menticoglou, S. , MDCM, FRCSC, A modified technique 65. Royal College of Obstetricians and Gynaecologists, to deliver the posterior arm in severe shoulder dystocia. Royal College of Midwives. Towards Safer Childbirth. Am J Obstet Gynecol 2006:108;3,2:755-57. Minimum Standards for the Organization of Labour Wards: Report of a Joint Working Party. London: RCOG 83. Cluver C, Hofmeyr GJ , Posterior Axilla Sling Traction Press; 1999. A Technique for Intractable Shoulder Dystocia. Obstet Gynecol 2009;113:486–8. 66. Macleod M, Strachan B, Bahl R, et al. A prospective cohort study of maternal and neonatal morbidity in rela- 84. Schramm M. Impacted shoulders: a personal experi- tion to use of episiotomy at operative vaginal delivery. ence. Aust NZ J Obstet Gynaecol 1983;23:28–31. BJOG. 2008 Dec;115(13):1688- 94. [LOE 1, prospective 85. Holman MS. A new manoeuvre for delivery of an cohort study with good follow-up] impacted shoulder, based on a mechanical analysis. 67. Gurewitch ED, Donithan M, Stallings SP et al. S Afr Med J. 1963;37:247–9. Episiotomy versus fetal manipulation in managing 86. Zelig, CM, Gherman RB. Modified Zavanelli maneuver severe shoulder dystocia: a comparison of outcomes. for the alleviation of shoulder dystocia. Obstet gynecol Am J Obstet Gynecol 2004;191:911-6. 2002;100:1112-4. 68. McFarland et al, Perinatal Outcome and the type of 87. Goodwin TM, et al. Catastrophic shoulder dystocia maneuvers in shoulder dystocia. Int Journal Gynecol and emergency symphysiotomy. Am J Obstet Gynecol Obstet 55;219-24,1996. (Level III) 1997;177:463-64. (Level III)

— Chapter I: Shoulder Dystocia — 23 88. Crichton D, Seedat EK. The technique of symphysiotomy. S African Med J 1963;37:227-31. (Level III) 89. Management of labor and delivery complications. (in) Douglas-Stromme Operative Obstetrics, 5th Edition. Zuspan FP, Quilligan EJ (eds.) Appleton and Lange. Norwalk, Connecticut. Pages 337-8, 1988. (Level III) 90. O’Shaughnessy MJ, Hysterotomy facilitation of the vaginal delivery of the posterior arm in a case of severe shoulder dystocia, Obstet Gynecol Oct 1998;92(4 Pt 2):693-5. (Level III) 91. Crofts J, Bartlett C, Ellis D, Fox R, Draycott T. Documentation of simulated shoulder dystocia: accurate and complete? BJOG 2008; 115:1303–1308. 92. Clark SL, Belfort MA, Dildy GA, and Meyers JA. Reducing Obstetric Litigation Through Alterations in Practice Patterns, Obstet Gynecol 2008;112:1279–83. 93. Clinical Negligence Scheme for Trusts. Maternity: Clinical Risk Management Standards. London: NHS Litigation Authority; 2006. [http://www.nhsla.com/NR/ rdonlyres/002DB3DE-F1A1-4153-AFE1-B59A3D743239/0/ CNSTMaternityStandardsApril2006final.pdf [LOE 3, opinion] 94. Nguyen T, Fox NS, Friedman Jr F, et al. The sequential effect of computerized delivery charting and simulation training on shoulder dystocia documentation. J of Mater Fetal Neonatal Med, 2011; Early Online, 1-5. 95. Deering S, Poggi S, Macedonia C, et al. Improving resident competency in the management of shoulder dystocia with simulation training. Obstet Gynecol. 2004;103:1224-1228. [LOE 3, other disease-oriented evidence] 96. Johannsson H, Ayida G, Sadler C. Faking it? Simulation in the training of obstetricians and gynaecologists. Curr Opin Obstet Gynecol. 2005;17:557-561. [LOE 3, opinion] 97. Black RS, Brocklehurst P. A systematic review of training in acute obstetric emergencies. BJOG 2003;110:837–841. [LOE 2, systematic review of studies with inconsistent findings] 98. Crofts JF, Bartlett C, Ellis D, et al. Management of shoulder dystocia: skill retention 6 and 12 months after training. Obstet Gynecol. 2007 Nov;110(5):1069-74. [LOE 2, lower-quality clinical trial]

24 — — Chapter I: Shoulder Dystocia SHOULDER DYSTOCIA DOCUMENTATION63

Date______Mother’s Name______

Time______Date of birth______

Person completing form______Designation______Hospital Number______

Signature______Consultant______

Called for help at: Emergency call via switchboard at: Staff present at delivery of head Additional staff attending for delivery of shoulders NAME ROLE NAME ROLE TIME ARRIVED

PROCEDURES USED TO BY WHOM TIME ORDER DETAILS REASON IF NOT ASSIST DELIVERY PERFORMED

McRoberts’ position

Suprapubic pressure From maternal left/right (circle as appropriate)

Episiotomy Enough access/tear present/already performed (circle as appropriate)

Delivery of posterior arm Right/left arm (circle as appropriate)

Internal rotational maneuver

Description of rotation

Description of traction Routine (as in normal Other – Reason if not routine vaginal delivery)

Other maneuvers used

Mode of delivery of head Spontaneous Instrumental — vacuum / forceps

Time of delivery of head Time of delivery of baby Head-to-body delivery interval

Fetal position during dystocia Head facing maternal left Head facing maternal right Left fetal shoulder anterior Right fetal shoulder anterior

Birth weight kg Apgar 1 min: 5 mins: 10 mins:

Cord gases Art pH: Art BE: Venous pH: Venous BE:

Explanation to parents Yes By:

Neonatal assessment at delivery Assessment by

Any sign of arm weakness? Yes No If yes to any of these questions for review and follow up by Consultant neonatologist. Any sign of potential bony fracture? Yes No Baby admitted to Neonatal Intensive Care Unit? Yes No

— Chapter I: Shoulder Dystocia — 25

Chapter J Postpartum Hemorrhage Ann Evensen, MD Janice Anderson, MD Published June 2014

OBJECTIVES After completing this chapter, participants will be able to: 1. List the important causes of postpartum hemorrhage. 2. Describe methods for preventing postpartum hemorrhage. 3. Discuss the need for early recognition and quick response to postpartum hemorrhage. 4. Describe the treatment of postpartum hemorrhage.

INTRODUCTION Postpartum hemorrhage (PPH) is excessive bleeding after delivery of the fetus and may occur before or after delivery of the placenta. Clinicians must learn to recognize excessive bleeding and intervene, preferably before other signs and symptoms of PPH develop (see Table 1).

Table 1. Signs and Symptoms of Postpartum Hemorrhage

Symptoms Signs

Lightheadedness Bleeding over 500 mL with vaginal delivery Weakness Hypotension Palpitations Tachycardia Restlessness Diaphoresis Confusion Syncope Air hunger Pallor Oliguria Hypoxia

DEFINITION, EPIDEMIOLOGY, AND SIGNIFICANCE Postpartum hemorrhage (PPH) is traditionally defined as the loss of more than 500 milliliters of blood following vaginal delivery or more than 1000 milliliters following cesarean delivery.1 PPH is considered severe when blood loss exceeds 1000 milliliters after vaginal delivery or results in signs or symptoms of hemodynamic instability.1 However, the definition of PPH is debated as more recent studies have shown that the median blood loss at spontaneous vaginal delivery exceeds 500 milliliters.2 Postpartum hemorrhage can be classified as primary, which occurs within 24 hours of delivery, or secondary, which occurs 24 hours to 12 weeks postpartum.3 Primary PPH is more common than secondary PPH.

Even with appropriate management, approximately five percent of obstetric patients will experience PPH, and one percent of vaginal deliveries will result in severe PPH.4-7 PPH is the number

— Chapter J: Postpartum Hemorrhage — 1 one cause of maternal mortality in developing countries and is the cause of 25 percent of maternal deaths worldwide.8 It is a common maternal morbidity in high resource countries and is trending upward.6

Potential sequelae of PPH include orthostatic hypotension, anemia and fatigue which can make breastfeeding and maternal care of the newborn more difficult.9 Postpartum hemorrhage may increase the risk of postpartum depression and acute stress reactions.9,10 Transfusion may be necessary and carries associated risks including infection and transfusion reaction.11 In the most severe cases, dilutional coagulopathy should be anticipated. Hemorrhagic shock may lead to Sheehan’s Syndrome (posterior pituitary ischemia with delay or failure of lactation), occult myocardial ischemia, or death.11,12

RISK FACTORS FOR POSTPARTUM HEMORRHAGE Risk factors include antepartum and intrapartum conditions as listed in Table 2. However, 20 percent of patients who develop postpartum hemorrhage have no risk factors, so providers must be prepared to treat it at every delivery.4

Table 2. Risk Factors for Postpartum Hemorrhage

Antepartum Risk Factors Labor Risk Factors Surgical Interventions • History of PPH (estimated • Prolonged labor • Operative vaginal delivery 10 percent recurrence with (first, second, and/or third stage) • Cesarean section 1 subsequent deliveries) • Preeclampsia and related disorders • Episiotomy • Nulliparity • Fetal demise • REFS 3,5,7,13 • Grand multiparity (> five deliveries) • Induction or augmentation • Coagulopathy (congenital • Use of magnesium sulfate or acquired including use of • Chorioamnionitis medications such as aspirin or heparin) • Abnormal placentation • Age > 30 years7,13 • Anemia • Overdistension of the uterus – Multiple gestation – Polyhydramnios – Fetal macrosomia

PREVENTION The best preventive strategy is active management of the third stage of labor (AMTSL).14 This includes 1) administering oxytocin with, or soon after, the delivery of the anterior shoulder and 2) cutting the cord after a delay of one to three minutes, 3) controlled cord traction to deliver the placenta, and 4) uterine massage after delivery of the placenta.14,15 To perform controlled cord traction, grasp the cord with one hand and gently apply traction while simultaneously applying subrapubic (NOT fundal) pressure with the other hand (called the “Brandt maneuver”).

2 — — Chapter J: Postpartum Hemorrhage Administration of a uterotonic drug is the most important step in reducing PPH.16 The benefits of the other steps are less clear.17 Earlier definitions of AMTSL did not include transabdominal uterine massage after placental delivery, but it is a reasonable approach and is now included in some AMTSL protocols.15,18,19 In addition, initial AMTSL protocols included cutting the umbilical cord immediately after delivery (less than 30 seconds). However, trials have shown that a delay in cord clamping of one to three minutes has benefits to the newborn without an increase in PPH or neonatal morbidity.20 These benefits include a decrease in anemia in pre-term and term infants and decrease in intraventricular hemorrhage in the very pre-term newborn.21,22

Active management decreases severe PPH, reduces the risk of postpartum anemia, and shortens the third stage of labor with no significant increase in cases of retained placenta.14,23,24 A reduction in the incidence of PPH also occurs if oxytocin is given after placental delivery.23 AMTSL is recommended by the American College of Obstetricians and Gynecologists (ACOG), International Federation of Gynecologists and Obstetricians (FIGO), International Confederation of Midwives (ICM), and the World Health Organization (WHO).1,25 Hospital guidelines that encourage the use of active management result in significant reduction in the incidence of severe PPH.26

Oxytocin (IM or IV) is the preferred uterotonic agent for preventing PPH because it is at least as effective and has fewer side effects than the ergot alkaloids and prostaglandins.16,23 There is a long-held view that intravenous administration of oxytocin increases the risk of transient hypotension, but a randomized controlled trial found that a 10-unit IV bolus in patients delivering vaginally did not cause significant hypotension.27 As many women in high resource settings have intravenous access, IV oxytocin is commonly used for AMTSL.28 A reasonable dose would be 5 to 10 units of oxytocin given as a bolus over one to two minutes.28 This dosing regimen requires oxytocin in a higher concentration than that used for labor induction or augmentation (for example, 10 units in 50 to 100 mL crystalloid bolus or 30 units in 500 mL crystalloid given as a 100 to 150 mL bolus followed by a maintenance infusion).

Misoprostol has been evaluated for prevention of PPH because of its advantages in resource- poor areas: it is inexpensive, heat and light stable, and can be administered without the use of syringes.29-31 Misoprostol (oral or sublingual) compared to placebo reduces severe PPH and blood transfusion.16,29-31 However, oxytocin remains the drug of choice for the prevention of PPH when available. In a meta-analysis of 29,797 women in 17 trials, oral misoprostol compared to conventional injectable uterotonics showed increased risk of severe PPH [relative risk (RR) 1.33; 95 percent confidence interval (CI) 1.16 to 1.52] and use of additional uterotonics but with fewer blood transfusions (RR) 0.84; 95 percent CI 0.66 to 1.06; 15 trials, 28,213 women).16 A randomized controlled trial of 652 women, which occurred after the meta-analysis, demonstrated superiority of powdered, sublingual misoprostol 400 mcg compared to intramuscular oxytocin 10 units (OR = 0.32; 95 percent CI 0.16 to 0.67) for the prevention of PPH.29 As in other studies, misoprostol had a greater incidence of side effects including increased shivering and fever.16,29 Misoprostol-related fever has a typical pattern: it is usually preceded by shivering, has an onset at less than 20 minutes postpartum, peaks at one to two hours, and spontaneously declines over three hours. One researcher recommended that women with this typical presentation of a postpartum fever after peripartum misoprostol are initially monitored with investigations and treatment only if the fever persists beyond three hours postpartum.32

— Chapter J: Postpartum Hemorrhage — 3 At this time, misoprostol should be used for prevention of PPH only when oxytocin is not available. The World Health Organization lists misoprostol as an essential medication for preventing PPH, but it is not FDA-approved for this indication.33 A reasonable dose is 600 micrograms orally.29-31 More research is needed in this area to define the most effective regimens for preventing PPH, especially in low resource and pre-hospital settings.

In addition to oxytocin given at the time of delivery, complications of PPH can be reduced by specific strategies before, during, and after labor.

Antenatally, patients who are at high risk for invasive placenta (such as prior uterine surgery, placenta previa, or coagulopathy) should have a sonogram.34,35 Women found to have invasive placenta and others at high risk of PPH should be delivered at a facility with blood bank, anesthesia, and surgical capabilities. All women should be screened for anemia and treated for reversible causes of anemia (e.g. iron deficiency, malaria). Women of African, Southeast Asian or Mediterranean descent should be offered screening for sickle cell or thalassemia by hemoglobin electrophoresis and complete blood count.36 Risks and benefits of these interventions should be discussed with patients and their choices documented. Clinicians should identify Jehovah’s Witnesses and other patients who refuse use of blood products.

Avoiding routine episiotomy, use of perineal warm compresses, and using a vacuum rather than forceps when assisted vaginal delivery is required may decrease the incidence of perineal trauma.37-39 Oxytocin and second line uterotonics (e.g. methylergonovine [Methergine], misoprostol, carboprost) should be readily available in the delivery suite and operating room. Vital signs and lochia should be assessed frequently to detect slow but significant blood loss.

For patients at very high risk of PPH, “type and cross” packed red blood cells (PRBCs) and other blood products should be readily available in the delivery suite or operating room. Women with anemia should have aggressive prevention and treatment of PPH as complications may occur at smaller volumes of blood loss.

DIAGNOSIS AND MANAGEMENT Preparation, early recognition, and quick response to excessive blood loss will reduce morbidity associated with both primary and secondary PPH. The diagnosis of PPH begins with recognition of excessive bleeding and methodical examination for its cause. The mnemonic, “The Four T’s – Tone, Trauma, Tissue, and Thrombin” can be used to remember specific causes (Table 3).

Table 3. Mnemonic for the Specific Causes of PPH – The Four Ts

Four Ts Specific Cause Relative Frequency

Tone Atonic uterus 70 percent

Trauma Lacerations, hematomas, inversion, rupture 20 percent

Tissue Retained tissue, invasive placenta 10 percent

Thrombin Coagulopathies 1 percent

4 — — Chapter J: Postpartum Hemorrhage GENERAL APPROACH TO A WOMAN WITH POSTPARTUM HERMORRHAGE Pregnant women have increased plasma volume and red blood cell mass.3 In addition, they are typically healthy and can accommodate mild to moderate blood loss without having signs or symptoms such as orthostasis, hypotension, tachycardia, nausea, dyspnea, oliguria, or chest pain. Blood loss should be monitored in every delivery and action taken before the woman develops symptoms. Once excessive blood loss is suspected, treatment must be initiated quickly by progressing through the Four T’s mnemonic (Tone, Trauma, Tissue, and Thrombin). As seen in Figure 1, many of the steps in diagnosis and management must be carried out simultaneously. Regardless of the suspected cause of bleeding, additional medical personnel will be needed to assist the delivering clinician. Assistants should be directed to start two large-bore intravenous lines (16 to 18 gauge). When bleeding occurs prior to placental delivery, attention is directed to its removal and inspection. If there is a delay in placental delivery or it is not intact, manual removal may be required. Difficulty locating a plane between the placenta and the uterus may signify invasive placenta.

After delivery of the placenta, vaginal bleeding will most often (70 percent) be due to uterine atony. The first maneuver to reduce bleeding is uterine massage. Oxytocin can be given next, via the (equally effective) intramuscular or intravenous route.1,28 If uterine tone does not improve with compression, massage, and oxytocin, a second uterotonic can be administered. During this time, the genital tract can be explored and lacerations repaired.

If vaginal bleeding persists after uterine atony has been treated and no lacerations or hematomas have been recognized, it is useful to explore the uterus (preferably after analgesia) to determine if retained placental fragments are responsible for continued bleeding. Uterine exploration will also allow detection of ruptured or partial uterine inversion. Hypotension or shock out of proportion to the amount of blood loss raises the suspicion for concealed hematomas, uterine rupture, or uterine inversion. Anaphylaxis, sepsis, and amniotic fluid or pulmonary embolism should also be considered. Persistent oozing or lack of clotting may signal a coagulopathy, sometimes caused by the hemorrhage itself.

Blood loss greater than 1500 milliliters requires immediate resuscitation measures using an interdisciplinary team approach, including anesthesia, laboratory, nursing, surgery, and blood bank staff. As part of the initial management of this emergency, clinicians should perform a primary maternal survey and institute care to support circulation, airway, and breathing (the ‘C-A-B’): 1) Open the airway and give supplemental oxygen to maintain oxygen saturation of greater than 95 percent. 2) Ventilate the patient if needed, with 100 percent oxygen. 3) Provide intravenous fluid and possibly blood replacement by starting two large bore IV’s with normal saline or other crystalloid fluids. Elevating the foot of the bed or having an assistant elevate the patient’s legs will improve venous return and raise the patient’s blood pressure.

After the primary maternal survey, obtain stat labs (type and cross, complete blood count, coagulation studies, and hold a red top for clot evaluation) if not already done when intravenous access is obtained. Place a Foley catheter to empty the bladder and monitor urine output. Heart rate and blood pressure should be monitored closely and times of relevant events should be documented. While vital sign changes may be delayed even with significant hemorrhage, the earliest to occur is tachycardia and narrowing pulse pressure. It may be necessary to infuse O-negative blood while waiting for type-specific blood. — Chapter J: Postpartum Hemorrhage — 5 Institute a “massive transfusion protocol,” if available, for any hemorrhage of greater than 1500 mls or ongoing blood-loss that is symptomatic.40,41 Research with critically injured trauma victims has shown improved survival with use of massive transfusion protocols that recommend infusion of fresh frozen plasma (FFP) and platelets whenever large numbers of PRBCs are needed. Typical massive transfusion protocol use ratios of four to six units of FFP and one unit of platelets for every six units of PRBCs without waiting for laboratory results to document coagulopathy.42,43 Dilutional coagulopathy may still occur with use of these protocols, so coagulation studies and platelet counts should be checked frequently and deficiencies corrected with additional FFP, platelets, and/or cryoprecipitate. Intractable hemorrhage may require uterine packing (plain gauze or soaked with vasopressin, chitosan or carboprost), placement of an intrauterine tamponade device (see description below), angiographic embolization, or hemostatic drugs such as recombinant factor VIIa.44-46 Compression of the aorta or the use of anti-shock garments can be done as a temporizing measure.44,47 Surgery may be required (e.g., B-lynch procedure [Figure 3], hemostatic multiple square suturing, surgical ligation of arteries, or hysterectomy).1,42 In the setting of continued hemorrhage despite use of bimanual massage, uterotonics and other surgical methods, a plan for rapid hysterectomy must be initiated as continued attempts at uterine conservation may increase the risk of maternal mortality.

UTERINE TAMPONADE DEVICES Uterine tamponade devices (Bakri™, ebb™, and BT Cath® balloons) can be used to limit uterine bleeding while definitive treatment is arranged and/or while patient is transported to a facility with more advanced surgical capabilities. A uterine tamponade balloon is placed through the cervix (after vaginal delivery) or through the abdominal and uterine incisions (after cesarean section or at the time of uterine surgery to treat recalcitrant postpartum hemorrhage). A uterine tamponade balloon works by pressing against the hemorrhaging endometrial surface with a force that exceeds the uterine arterial and venous blood pressure. Uterine tamponade balloons are contraindicated in cases of allergy to the balloon material (latex, rubber), genital tract infection, cervical cancer, pregnancy, anomalies that distort the uterine cavity (e.g. large leiomyoma, congenital anomalies) and in situations where other treatment (e.g., arterial embolization, surgical exploration, hysterectomy) is needed. Studies of uterine tamponade balloons have been done with case series and their use is recommended in consensus guidelines.33,45,48,49 The potential danger of postpartum hemorrhage makes the design of an RCT to evaluate tamponade balloons very unlikely. Manufacturers of uterine tamponade balloons have published instructions for safe use of their devices: Bakri™ balloon: https://www.cookmedical.com/product/-/catalog/bakri-postpartum-balloon?ds=wh_sos_webds ebb™ Balloon: http://www.bmmedical.co.uk/products/obstetrics/ebb/ BT Cath® Balloon: http://www.utahmed.com/btcath.htm

Clinicians should be familiar with the device that is available to them locally. Because the balloon is a temporary device and may fail or require a definitive treatment such as a B-lynch uterine suture or hysterectomy, a surgeon should be notified at the time of placement.

In secondary PPH (24 hours to six weeks after delivery), atony is still the most likely cause of bleeding.

6 — — Chapter J: Postpartum Hemorrhage Bleeding may occur at a slow rate, obscuring the overall volume of blood loss. Endometritis may complicate diagnosis and management. Pelvic ultrasound or Doppler studies may be used, but nondiagnostic findings are common. Careful curettage may be needed to remove retained tissue.1

Please see the ALSO® Chapter on Maternal Resuscitation for a general response to hemorrhage and related emergencies.

CAUSE-SPECIFIC APPROACH TO POSTPARTUM HEMORRHAGE

Figure 1. “The Four Ts” and Management of PPH

Active Management of the Third Stage Oxytocin with or soon after delivery Cut cord in one to three minutes Controlled cord traction Uterine massage after placenta delivers

Blood loss > 500 ml, brisk bleeding, BP falling, HR rising and/or symptoms Bimanual uterine massage POSTPARTUM HEMORRHAGE Resuscitation Oxytocin 20 IU (range 10 to 40) in 1L NS Use team approach Two large bore IVs infuse 500 mL over 10 min Oxygen by mask then 250 mL/hour Monitor BP, HR, urine output CBC, type and cross match Determine cause: Four Ts Soft “boggy” uterus Genital tract tear Placental retained Blood not clotting TONE Inversion of the uterus TISSUE THROMBIN TRAUMA

Carboprost 0.25 mg IM or IMM Suture lacerations Inspect placenta Check coags Misoprostol 800 to 1000 mcg SL, PO or PR Drain hematomas > 5 cm Manual removal (analgesia) Replace factors Methylergonovine 0.2 mg IM Replace inverted uterus Curettage Fresh frozen plasma or Ergometrine 0.5 mg IM Blood loss > 1000 ml: Severe PPH Transfuse RBCs, platelets, clotting factors Consult anesthesia, surgery

Blood loss > 1500 ml: Institute massive transfusion protocol Uterine packing/tamponade procedure Vessel embolization/ligation/compression sutures Recombinant factor Vlla Support BP with vasopressors Consider intensive care unit Hysterectomy

Many of the steps involved in diagnosing and treating PPH can be undertaken simultaneously. Abbreviations: BP = blood pressure, cm = centimeter, HR= heart rate, IM = intramuscularly, IMM = intramyometrially, IU = international units, mL= milliliters, min = minutes, mg = milligrams, NS = normal saline, PO= by mouth, PR= per rectum, RBCs = red blood cells, SL=sublingually, coags = coagulation screen: platelet count, prothrombin time (INR), partial thromboplastin time, fibrinogen level, and fibrin split products (d-dimer).

— Chapter J: Postpartum Hemorrhage — 7 Figure 2. Transcervical Placement of Bakri Balloon Catheter for Tamponade of Uterine Hemorrhage

Figure 3. B-Lynch Suture of Uterus for Severe Hemorrhage

(a) Anterior View (b) Posterior View (c) Anterior View

8 — — Chapter J: Postpartum Hemorrhage

TONE Uterine atony is the most common cause of PPH.50 Because hemostasis following placental separation depends on myometrial contraction, transabdominal massage is recommended following delivery of the placenta in every delivery.19 Atony unresponsive to transabdominal massage is treated initially by bimanual uterine massage while awaiting drugs that promote contraction of the uterus.

Uterine Massage The appropriate response to a soft, “boggy” uterus and brisk flow of blood from the vagina after delivery of the placenta is bimanual uterine massage. To perform bimanual massage, the clinician uses one hand over the lower abdomen to massage the uterine fundus and one hand in the vaginal vault to massage the lower uterine segment. The position of the clinician’s hands with respect to the uterus depends on the position of the uterus and the patient’s body habitus. Figure 4 shows an anteverted uterus with the clinician’s hand on the abdomen massaging the posterior aspect of the uterus. Two or more fingers of the vaginal hand are typically used for bimanual massage. Using the entire vaginal hand or fist to compress the uterus may be necessary for severe, persistent atony.

Figure 4. Bimanual massage for uterine atony

— Chapter J: Postpartum Hemorrhage — 9 Uterotonic Agents Uterotonic agents include oxytocin (Pitocin®, Syntocinon®), prostaglandins, and ergot alkaloids (Table 4). Uterotonic agents stimulate the myometrium to contract, constricting spiral arteries and decreasing blood flow through the uterus. Oxytocin is an effective first line treatment for PPH.1 Oxytocin 20 to 40 units can be added to one liter of normal saline. An initial 500 ml (10 to 20 units of oxytocin) can be infused over 10 minutes without complications. Following this initial infusion, the oxytocin solution can be infused intravenously at 250 ml per hour. If atonic hemorrhage continues, the rate of infusion or oxytocin concentration may be increased (e.g. 40 to 80 units of oxytocin in one liter of normal saline).48

If oxytocin alone is insufficient to improve uterine atony and hemorrhage, the choice of second-line agent should be based upon patient factors (such as the presence of hypertension or asthma) and local maternity care practices. Methylergonovine (Methergine®) and ergometrine (Ergonovine®, not available in the U.S.) are ergot alkaloids that stimulate uterine muscle contraction.50 A typical dose is 0.2 mg IM.1,48,50 It can be repeated every two to four hours. Because ergot alkaloids agents cause vasoconstriction and raise blood pressure, they are contraindicated in women with preeclampsia, gestational hypertension, or chronic hypertension. Other adverse effects include nausea and vomiting. They should not be used in patients with HIV taking protease inhibitors. Protease inhibitors increase circulat- ing levels of ergots; this increases their potential for side effects including arteriolar spasm and stroke.51

Prostaglandins such as 15-methyl prostaglandin F-2a (carboprost, Hemabate®) and misoprostol (Cytotec®) are strong uterotonics and can be used when adequate tone is not achieved with oxytocin .16

Carboprost is given IM in a dose of 0.25 mg, and can be repeated every 15 minutes for a total dose of 2 mg. Carboprost can be used at the same dose injected into the myometrium, typically during cesarean section or a postpartum surgical procedure to treat severe PPH. Carboprost has been shown to control hemorrhage in up to 87 percent of cases.52 In cases where it was not effective, chorioamnionitis or other risk factors for hemorrhage were often present.52 Hypersensitivity is the only absolute contraindication, but carboprost should usually be avoided in patients with asthma, hypertension, or significant cardiac or renal disease. Common side effects include nausea, vomiting, and diarrhea.16

Misoprostol (Cytotec®) can be administered by sublingual, oral, vaginal, or rectal routes, sometimes in combination.29-31,53 Oral and sublingual dosing allow more rapid onset of action, but rectal dosing allows for longer duration of action and fewer gastrointestinal side effects. Acceptable dosages are 800 to 1000 mcg rectally or 600 to 800 mcg orally or sublingually.1,31,33,50,54 Higher levels and larger doses are associated with more side effects including shivering, pyrexia, and diarrhea.50 Even at low doses, misoprostol use is associated with more side effects than oxytocin use.55 The use of misoprostol in addition to oxytocin does not significantly improve treatment of PPH as compared to oxytocin alone, especially if prophylactic oxytocin has already been given as part of the AMTSL.33,55,56 Misoprostol has not been approved by the US Food and Drug Administration for the treatment of PPH. However, its use for PPH is recommended in the ACOG postpartum hemorrhage patient safety checklist.48

After initial stabilization of a patient with atony, ongoing monitoring is necessary, including checking of vital signs and assessment of any ongoing or recurrent bleeding. Methylergonovine (such as 0.2 mg by mouth every four hours for four doses) or oxytocin (such as 10 to 20 units in one liter of normal saline infused over four to six hours) can be given to maintain uterine tone.

10 — — Chapter J: Postpartum Hemorrhage Table 4. Medications Used for Prevention and Treatment of Postpartum Hemorrhage Medication Dose Prevention Treatment Contraindications/ Mechanism of Side effects Cautions Action / Comments

First Line Agent: Oxytocin Prevention: + + Overdose or Stimulates the Rare (Pitocin®, 10 IU IM or 5 to prolonged use upper segment of Syntocinon®) 10 IU IV bolus can cause water the myometrium to intoxication contract rhythmi- Treatment: cally, constricting 20 to 40 IU in Possible hypoten- spiral arteries 1000 ml NS. Infuse sion with IV use decreasing blood 500 ml over 10 following cesarean flow through the minutes then section uterus. 250 ml/hour

Second Line Agent: Carboprost 0.25 mg, IM or - + Avoid in patients Improves uterine Nausea, (Hemabate®) into myometrium with asthma or contractility vomiting, repeated every significant renal, by increasing and diarrhea Prostaglandin 15 to 90 minutes hepatic or cardiac the number of F-2α analog for a total dose of disease oxytocin recep- 2 mg tors and causes vasoconstriction

Methylergonovine 0.2 mg IM - + Avoid in hyper- Vasoconstriction Nausea, (Methergine®) repeat every two tensive disorders and contracts vomiting, Not used to four hours of pregnancy smooth muscles and ______in the US including chronic upper and lower increased ______for preven- Ergometrine hypertension segments of the B/P tion due to (Ergonovine®) 0.5 mg IM uterus tetanically potential Caution in patients [not available in Used IV in side with HIV taking the US] countries other effects protease inhibitors May be combined than the US with oxytocin as Syntometrine in United Kingdom and other nations

Misoprostol Prevention: + + Caution in patients Generalized Nausea, (Cytotec®)* 600 mcg oral with cardiovascular smooth muscle vomiting, Use only disease contraction diarrhea, Prostaglandin E1 Treatment: 800 to when oxy- pyrexia, and analog 1000 mcg rectally, tocin is not shivering or 600 to 800 available mcg sublingually or orally

Table References1,14,16,30,31,33,50,52,54,57 Table Footnotes: Abbreviations: IM intramuscular, NS normal saline, BP blood pressure, AMTSL active management of third stage of labor. *Misoprostol is not approved by the U.S. Food and Drug Administration for use in prevention or treatment of postpartum hemorrhage.

— Chapter J: Postpartum Hemorrhage — 11 TRAUMA Lacerations and hematomas resulting from birth trauma can cause significant blood loss that can be lessened by hemostasis and timely repair. Sutures for hemostasis are placed if direct pressure does not stop the bleeding. Episiotomy increases blood loss as well as the risk of anal sphincter tears and should be avoided unless urgent delivery is necessary and the perineum is felt to be a limiting factor in achieving delivery.13,38

Hematomas can present as pain or as a change in vital signs out of proportion to the amount of blood loss observed. Patients with persistent signs of volume loss despite fluid replacement, or with large or enlarging hematomas, require incision and evacuation of the clot.58 The involved area should be irrigated and the bleeding vessels ligated. Often a specific vessel cannot be identified and hemostatic figure of eight sutures are placed. Where there is diffuse oozing, a layered closure will help to secure hemostasis and eliminate dead space. Small, nonexpanding vaginal or vulvar hematomas (typically less than 4 cm) can be managed conservatively with ice packs, analgesia, and continued observation.58

Uterine Inversion Uterine inversion is rare, occurring in about one in 2,500 deliveries.59 Active management of the third stage, including the Brandt maneuver described above, does not appear to increase the incidence of uterine inversion.59,60 Fundal, adherent, or invasive implantation of the placenta may lead to inversion; the role of fundal pressure and undue cord traction are uncertain.61 The patient may show signs of shock (pallor, hypotension) without excess blood loss. Upon inspection, the inverted uterus may be in the vaginal vault or may protrude from the vagina, appearing as a bluish-gray mass that may not be readily identifiable as an inverted uterus. Roughly half the time, the placenta is still attached and it should be left in place until after reduction to limit hemorrhage.59 If oxytocin is running, it should be stopped, and an attempt should be made to replace the uterus quickly. There are several methods for reduction. The Johnson method involves grasping the protruding fundus with palm of the hand, fingers directed toward the posterior fornix. The uterus is returned to position by lifting it up through the pelvis and into the abdomen with steady pressure towards the umbilicus.59 Once the uterus is reverted, uterotonic agents should be given to promote uterine tone and prevent recurrence. If initial attempts to replace the uterus have failed or a cervical contraction ring develops, terbutaline, nitroglycerin, or general anesthesia may allow sufficient uterine relaxation for manipulation.59

Uterine Rupture Although rare in an unscarred uterus, clinically significant uterine rupture complicates approximately 0.8 percent of trials of labor after cesarean (TOLAC) at term.62 The risk is significantly increased in women with previous classical uterine incisions or a myomectomy that goes completely though the uterine wall; these women should not have a trial of labor and should be delivered by elective cesarean at 37 to 38 weeks.63 Risk of uterine rupture is increased to a lesser extent with shorter intervals between pregnancies or a history of multiple prior cesarean sections, particularly with no previous vaginal delivery.64,65 Compared to spontaneous labor, induction of a patient with a uterine scar increases the rate of uterine rupture to 1.0 to 1.5 percent.62,64-66 The use of prostaglandins for cervical ripening appears to be associated with an increased risk of uterine rupture.66 Although the evidence with regard to specific prostaglandins is limited, misoprostol (PGE1) is considered to be contraindicated while the use of the dinoprostone insert (Cervidil®, PGE2) remains controversial.64,66

12 — — Chapter J: Postpartum Hemorrhage The dinoprostone insert has the advantage of being easily removed if tachysytole or concerning fetal heart rate decelerations occur. Foley balloon may be considered for cervical ripening if induction is indicated in a patient desiring TOLAC.64

During labor, the first sign of uterine rupture is usually fetal heart rate changes such as fetal bradycardia.64,67 Other signs or symptoms include: vaginal bleeding, abdominal tenderness, increasing abdominal girth, loss of uterine contractions, elevation of presenting fetal part, maternal tachycardia, or circulatory collapse.64

Uterine rupture can cause harm to both fetus and mother. Uterine rupture may require surgical repair of the defect, blood transfusion, or hysterectomy. Small, asymptomatic lower uterine segment defects incidentally noted on postpartum uterine exploration can be followed expectantly.64 An Agency for Healthcare Research and Quality (AHRQ) sponsored summary about trial of labor (TOL) found no maternal deaths from uterine rupture among patients with term pregnancies. This report calculated that the overall maternal mortality was 13.4 per 100,000 for elective repeat cesarean delivery (ERCD) and 3.8 per 100,000 for TOLAC.66 The rates of hysterectomy, hemorrhage, and transfusions did not differ significantly between TOLAC and ERCD.

Although maternal mortality is reduced by choosing TOLAC over ERCD, this choice is associated with increased fetal mortality. ERCD is associated with 0.5 perinatal deaths per 1000 births compared with 1.3 perinatal deaths per 1000 TOLAC births.66 This TOLAC perinatal mortality rate is comparable to the perinatal mortality rate of laboring nulliparous women.62 Hypoxic ischemic encephalopathy (HIE) is also slightly higher for TOLAC compared with ERCD, but “it is not possible to know the true relationship due to the low strength of overall evidence.”62,66,67

TISSUE Retained tissue (placenta, placental fragments, and blood clots) prevents the uterus from contracting enough to achieve optimal tone.

Retained Placenta A small gush of blood with lengthening of the cord and a slight rise of the uterus in the pelvis are the classic signs of placental separation. Firm traction on the umbilical cord with one hand while the other applies suprapubic counter-pressure (Brandt maneuver) typically achieves placental delivery. The mean time from delivery until placental expulsion is eight to nine minutes.5 A longer interval is associated with an increased risk of PPH, doubling after 10 minutes.5 Retained placenta, defined as the failure of the placenta to deliver within 30 minutes after birth, occurs in less than three percent of vaginal deliveries.68 Injecting the umbilical vein with saline and oxytocin (UVI) does not reduce the risk of retained placenta.69

If the placenta does not deliver after 30 minutes, manual removal of the placenta should be considered.70 If the patient is stable, taking time to establish adequate analgesia is strongly recommended. This will make the procedure easier to perform and will reduce the patient’s emotional and physical distress.

— Chapter J: Postpartum Hemorrhage — 13 To manually remove the placenta: 1. Cease uterine massage and allow the uterus to relax. Subcutaneous or intravenous terbutaline 0.25 mg, intravenous nitroglycerin 100 to 200 mcg, or general anesthesia may infrequently be required to relax the uterus.71 When medications for uterine relaxation are administered the patient can lose large amounts of blood, so it becomes imperative to accomplish the removal rapidly and then reverse the relaxation with oxytocic agents. 2. Identify the cleavage plane between the placenta and the uterine wall. Advance your fingertips in the plane until the entire placenta is free. 3. Cup the separated cotyledons into your palm. Deliver the placenta intact if possible. 4. After examining the uterine cavity and the placenta to ensure that the entire placenta and membranes have been removed, massage the uterus and give oxytocin.

If the cleavage plane cannot be identified or parts of the plane cannot be developed completely, prepare for surgical removal of the placenta: 1. Ensure that the patient has oxygen, two large bore intravenous catheters with replacement fluids running, adequate anesthesia started, proper surgical setup available, and appropriately trained providers present. Then, remove placental tissue either by vacuum or blunt curettage. 2. Curette the uterine cavity with a large blunt curette or large suction catheter. Take care to prevent perforating the soft, postpartum uterus. 3. Use ring forceps to grasp and remove placental tissue.

Invasive placenta can be life threatening.68 The incidence has increased to at least 0.04 percent of deliveries, likely related to the increase in cesarean section rates.35 Other risk factors include: prior invasive placenta, placenta previa (especially in combination with prior cesarean sections, increasing to 67 percent with placenta previa and four or more prior cesareans), advanced maternal age, and high parity.35,68

Classification is based on the depth of invasion. Placenta accreta adheres to the myometrium, placenta increta invades the myometrium, and placenta percreta penetrates the myometrium to or beyond the serosa.35,68 The usual treatment for invasive placenta is hysterectomy. For select patients, however, conservative management is sometimes successful. Conservative treatment options include partial removal of the placenta, arterial embolization, methotrexate and/or watchful waiting.35,72 Women treated for a retained placenta must be observed for late sequelae, including infection and late postpartum bleeding.35, 72

THROMBIN Coagulation disorders, a rare cause of PPH, are unlikely to respond to the uterine massage, uterotonics, and repair of lacerations.1 Coagulation defects may be the cause and/or the result of a hemorrhage and should be suspected in those patients who have not responded to the usual measures to treat PPH, are not forming blood clots, or are oozing from puncture sites.

Many patients taking medications such as heparin or aspirin or who have chronic coagulopathies such as idiopathic thrombocytopenic purpura, thrombotic thrombocytopenic purpura, von Willebrand’s disease, and hemophilia are identified prior to delivery, allowing advanced planning to prevent PPH. Coagulopathic bleeding before or during labor can be the result of HELLP syndrome (Hemolysis

14 — — Chapter J: Postpartum Hemorrhage Elevated Liver enzymes and Low Platelets) or disseminated intravascular coagulation (DIC). Obstetric conditions that can cause DIC include severe preeclampsia, amniotic fluid embolism, sepsis, placental abruption (often associated with cocaine use or hypertensive disorders), massive PPH and prolonged retention of fetal demise.73

Evaluation should include a platelet count, prothrombin time (INR), partial thromboplastin time, fibrinogen level, and fibrin split products (d-dimer). If rapid laboratory testing is not available, an empty whole blood tube (“red top”) can be filled with maternal blood and taped to the wall. It should form a clot within five to 10 minutes. Management of coagulopathy consists of treating the underlying disease process, serially evaluating the coagulation status, replacing appropriate blood components, and supporting intravascular volume, using a massive transfusion protocol if indicated.41,73

POSTSTABILIZATION CARE AND DEBRIEFING Postpartum hemorrhage can be frightening for the woman, her family, and her medical caregivers. Nine percent of women screen positive for posttraumatic stress disorder (PTSD) due to traumatic childbirth.74 Treatment of a woman with postpartum hemorrhage does not conclude with control of bleeding and stabilization of her vital signs. Screening for, diagnosing, and treating acute stress disorder (occurring in the first month post-trauma) or PTSD is warranted to prevent long-term emotional sequelae. In addition to support of the health care team, patients with acute stress symptoms benefit from cognitive behavioral therapy.75 Please see ALSO Birth Crisis chapter and workstation for more information regarding recommended post-trauma procedures and support for clinical staff.

Preventing Complications from PPH: A Systems-Based Approach Complications of PPH are too common, even in high-resource countries and well-staffed delivery suites. Based on analysis of systems errors identified in The Joint Commission’s 2010 Sentinel Event Alert, the Commission recommended that hospitals “identify specific triggers for responding to changes in the mother’s vital signs and clinical condition and develop and use protocols and drills for responding to change, such as hemorrhage. Hospitals should use the drills to train staff in the protocols, to refine local protocols, and to identify and fix systems problems that would prevent optimal care.”76 The use of a massive transfusion protocol is one example of a systems approach to respond to obstetric emergencies.

ALSO training can be part of a systems approach to improve patient care. The use of interdisciplinary team training with in-situ simulation has been shown to improve perinatal safety.77 Training hospital maternity care staff in an ALSO Provider course in a Tanzanian referral hospital significantly reduced the incidence of PPH and severe PPH.78

Global Perspectives: PPH Although there is risk of PPH at every delivery, severe complications of PPH including maternal mortality are most common in developing countries.6,7,33 Table 2 lists PPH risk factors, some of which may be more significant in developing countries, e.g., prolonged labor and chronic anemia from malnutrition or parasitic infections. Lack of skilled attendants, lack of access to medications to prevent and treat hemorrhage, and great distances from medical centers capable of providing blood transfusions and surgery further increase risks of PPH morbidity and mortality.79 Uterine atony accounts for the majority of PPH in all settings. It is also important to consider causes that are more

— Chapter J: Postpartum Hemorrhage — 15 common in low resource areas such as uterine rupture following prolonged/obstructed labors and genital tract lacerations in patients with female genital circumcision.

If used at every birth, active management of the third stage of labor would reduce PPH by 30 to 50 percent.14,23 Oxytocin is the preferred drug for PPH prevention and treatment. However, it requires refrigeration and the use of vials and needles.80 A single-dose, prefilled syringe, Uniject (Becton Dickinson, Franklin Lakes, NJ, USA) has been developed to decrease complexity of use.81 If a health center cannot use or store oxytocin safely, misoprostol may be the preferred drug for prevention and treatment of PPH.6 Misoprostol availability in some countries may be limited due to legal or political concerns related to the potential use of misoprostol for elective pregnancy termination. Other prevention strategies include: 1) detecting and correcting maternal anemia prior to delivery, and 2) avoiding unnecessary instrumental deliveries and routine episiotomy.7,36,38 Treatment possibilities being evaluated for use in developing countries include the use of anti-shock garments and uterine tamponade with a hydrostatic condom catheter (sterile rubber catheter fitted with a condom, placed into the uterus through the vagina and inflated with 250 to 500 ml of saline).47 Proprietary devices such as the Bakri™ balloon are effective for uterine atony but may not be readily available due to financial and logistical concerns.45

Additional details regarding PPH in developing countries can be found in the PPH Chapter Addendum of the Global ALSO Manual (available by calling (800) 274-2237 and at www.aafp.org/ globalalso). In addition, the Global ALSO Maternal Resuscitation Chapter Addendum contains information on blood banking and blood transfusion.

SUMMARY Postpartum hemorrhage is unpredictable and can occur in women with no risk factors. Active management of the third stage of labor (AMTSL) should be used routinely. AMTSL includes oxytocin after delivery of the fetal anterior shoulder and controlled cord traction with the Brandt maneuver. Uterine massage after delivery of the placenta is a reasonable approach and is included in some AMTSL protocols. Delayed cord clamping (one to three minutes after delivery) may be considered to decrease risk of infant anemia without increasing maternal hemorrhage risk.

Management of PPH requires rapid diagnosis and treatment. Diagnosis and treatment occur simultaneously using “The Four Ts” mnemonic. Uterine atony (TONE) is responsible for the majority of PPH, and can be effectively treated with uterine massage and uterotonic medications (oxytocin, misoprostol, methylergonovine, and 15-methyl prostaglandin F2 alpha). Oxytocin remains the first line medical treatment for treatment of PPH due to atony. TRAUMA, such as perineal lacerations and hematomas, is the second most common cause of PPH and may require intervention. The third most common cause of PPH, TISSUE, requires careful uterine exploration to remove clot and retained placenta and anticipation of the rare cases with invasive placenta. For women with suspected coagulopathy such as DIC, clotting factors need to be replaced and the cause of coagulopathy identified and corrected (THROMBIN). Early recognition, systematic evaluation and treatment, and prompt fluid resuscitation minimize the morbidity and mortality associated with postpartum hemorrhage, regardless of cause.

16 — — Chapter J: Postpartum Hemorrhage SUMMARY OF RECOMMENDATIONS Strength of Recommendation – A Active management of the third stage of labor should be utilized to decrease the risk of postpartum hemorrhage, postpartum maternal hemoglobin less than 9 mg/dL, and the need for manual removal of the placenta.14,23

Delayed cord clamping (one to three minutes) decreases neonatal risk of anemia and does not increase risk of PPH.20-22

Oxytocin remains the first choice for prevention of PPH because it is as, or more, effective than ergot alkaloids or prostaglandins and has fewer side effects.16,22

Misoprostol has advantages for prevention in low-resource settings because it is effective (NNT 18), inexpensive, heat stable, and simple to administer.29,30

Misoprostol is less effective for prevention of postpartum hemorrhage than oxytocin and has more side effects.50,55,56

Strength of Recommendation – B The use of interdisciplinary team training with in-situ simulation has been shown to improve perinatal safety.77

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OB Hemorrhage Care Guideline. 2010. (Accessed Inferiority Trial. Lancet 2010;375:210-6. November 20, 2013, 2013, At https://http://www.cmqcc. org/resources/ob_hemorrhage/ob_hemorrhage_care_ 54. Treatment of Post-Partum Haemorrhage with Misoprostol. guidelines_checklist_flowchart_tablechart_v1_4.) Figo, 2012. (Accessed Nov 22, 2013, At http://www. k4health.org/sites/default/files/treatment of Post-Partum 41. Burtelow M, Riley E, Druzin M, Fontaine M, Viele M, Haemorrhage With Misoprostol Figo Guideline.Pdf.) Goodnough Lt. How We Treat: Management of Life- Threatening Primary Postpartum Hemorrhage with a 55. Blum J, Winikoff B, Raghavan S, Et Al. Treatment of Standardized Massive Transfusion Protocol. Transfusion Post-Partum Haemorrhage with Sublingual Misoprostol 2007;47:1564-72. Versus Oxytocin in Women Receiving Prophylactic Oxytocin: A Double-Blind, Randomised, Non-Inferiority 42. Prevention and Management of Postpartum Trial. Lancet 2010;375:217-23. Haemorrhage. Guidelines and Audit Committee of the Royal College of Obstetricians and Gynaecologists, 56. Widmer M, Blum J, Hofmeyr GJ, Et Al. Misoprostol as 2009. (Accessed Nov 22, 2013, At http://www.rcog.org. an Adjunct to Standard Uterotonics for Treatment of uk/eomens-health/vlinical-guidance/prevention-and- Post-Partum Haemorrhage: A Multicentre, Double-Blind management-postpartum-haemorrhage-green-top-52.) Randomised Trial. Lancet 2010;375:1808-13.

— Chapter J: Postpartum Hemorrhage — 19 57. Dildy GA, 3rd. Postpartum Hemorrhage: New 73. Richey ME, Gilstrap LC, 3rd, Ramin Sm. Management Management Options. Clinical Obstetrics and of Disseminated Intravascular Coagulopathy. Clinical Gynecology 2002;45:330-44. Obstetrics And Gynecology 1995;38:514-20. 58. Benrubi G, Neuman C, Nuss RC, Thompson RJ. Vulvar 74. Beck CT, Gable RK, Sakala C, Declercq Er. and Vaginal Hematomas: A Retrospective Study of Posttraumatic Stress Disorder in New Mothers: Conservative Versus Operative Management. Southern Results from a Two-Stage U.S. National Survey. Birth Medical Journal 1987;80:991-4. 2011;38:216-27. 59. You WB, Zahn CM. Postpartum Hemorrhage: 75. Roberts NP, Kitchiner NJ, Kenardy J, Bisson JI. Early Abnormally Adherent Placenta, Uterine Inversion, Psychological Interventions to Treat Acute Traumatic and Puerperal Hematomas. Clinical Obstetrics and Stress Symptoms. Cochrane Database Syst Rev Gynecology 2006;49:184-97. 2010:Cd007944. 60. Gulmezoglu AM, Widmer M, Merialdi M, Et Al. Active 76. Jointcommision. Preventing Maternal Death. Jt Comm Management of the Third Stage of Labour Without Perspect Jrnl 2010;30:7-9. Controlled Cord Traction: A Randomized Non-Inferiority 77. Riley W, Davis S, Miller K, Hansen H, Sainfort F, Sweet Controlled Trial. Reproductive Health 2009;6:2. R. Didactic and Simulation Nontechnical Skills Team 61. Shah-Hosseini R, Evrard Jr. Puerperal Uterine Training to Improve Perinatal Patient Outcomes in Inversion. Obstetrics and Gynecology 1989;73:567-70. a Community Hospital. Joint Commission Journal 62. Cunningham GF. National Institutes of Health on Quality And Patient Safety/Joint Commission Consensus Development Conference Statement: Resources 2011;37:357-64. Vaginal Birth after Cesarean: New Insights March 8-10, 78. Sorensen Bl, Rasch V, Massawe S, Nyakina J, Elsass 2010. Obstetrics And Gynecology 2010;115:1279-95. P, Nielsen BB. Advanced Life Support in Obstetrics 63. Spong CY, Mercer BM, D’Alton M, Kilpatrick S, (ALSO) and Post-Partum Hemorrhage: A Prospective Blackwell S, Saade G. Timing of Indicated Late-Preterm Intervention Study in Tanzania. Acta Obstetricia Et 2011;90:609-14. and Early-Term Birth. Obstetrics and Gynecology Gynecologica Scandinavica 2011;118:323-33. 79. Ronsmans C, Graham WJ. Maternal Mortality: Who, 64. ACOG. ACOG Practice Bulletin No. 115: Vaginal Birth When, Where, And Why. Lancet 2006;368:1189-200. after Previous Cesarean Delivery. Obstetrics and 80. Gard JW, Alexander JM, Bawdon Re, Albrecht JT. Gynecology 2010;116:450-63. Oxytocin Preparation Stability in Several Common 65. Landon MB, Hauth JC, Leveno KJ, Et Al. Maternal Obstetric Intravenous Solutions. American Journal Of and Perinatal Outcomes Associated with a Trial of Obstetrics And Gynecology 2002;186:496-8. Labor after Prior Cesarean Delivery. The New England 81. Althabe F, Mazzoni A, Cafferata Ml, Et Al. Using Journal Of Medicine 2004;351:2581-9. Uniject to Increase the Use of Prophylactic Oxytocin 66. Guise JM, Eden K, Emeis C, Et Al. Vaginal Birth after for Management of the Third Stage of Labor in Latin Cesarean: New Insights. Evidence Report/Technology America. International Journal of Gynaecology and Assessment 2010:1-397. Obstetrics: The Official Organ of the International Federation of Gynaecology and Obstetrics 67. Guise JM, McDonagh MS, Osterweil P, Nygren P, Chan 2011;114:184-9. BK, Helfand M. Systematic Review of the Incidence and Consequences of Uterine Rupture in Women with Previous Caesarean Section. BMJ 2004;329:19-25. 68. Wu S, Kocherginsky M, Hibbard JU. Abnormal Placentation: Twenty-Year Analysis. American Journal Of Obstetrics and Gynecology 2005;192:1458-61. 69. Nardin JM, Weeks A, Carroli G. Umbilical Vein Injection for Management of Retained Placenta. Cochrane Database Syst Rev 2011:Cd001337. 70. Weeks Ad. The Retained Placenta. Best Practice & Research Clinical Obstetrics & Gynaecology 2008;22:1103-17. 71. Axemo P, Fu X, Lindberg B, Ulmsten U, Wessen A. Intravenous Nitroglycerin for Rapid Uterine Relaxation. Acta Obstetricia Et Gynecologica Scandinavica 1998;77:50-3. 72. Timmermans S, Van Hof AC, Duvekot JJ. Conservative Management of Abnormally Invasive Placentation. Obstetrical & Gynecological Survey 2007;62:529-39.

20 — — Chapter J: Postpartum Hemorrhage Chapter K Maternal Resuscitation and Trauma (including Amniotic fluid embolism)

Neil J. Murphy, MD Brendon Cullinan, MD

Published June 2014

OBJECTIVES At the end of this lecture, participants will be able to: 1. Describe the aspects of maternal physiology that affect maternal resuscitation and response to trauma during pregnancy. 2. List the modifications of basic life support and advanced cardiac life support needed in pregnancy. 3. Describe the technique for emergency hysterotomy (cesarean delivery). 4. Describe the evaluation and management of trauma, major and minor, related to pregnancy.

CASE SCENARIO JE is 36 yo G5 P3, 0, 1, 3 at 38 6/7 weeks gestation in active labor who you have been following since her first prenatal visit at nine weeks. Her prenatal risk factors include gestational hypertension, gestational diabetes Class A 1, and a history of recent intimate partner violence.

JE was 7 cm dilated at 0 station and having uterine contractions every two to three minutes with a reassuring fetal heart rate pattern. You have been called away to assist at a cesarean delivery with a colleague on another patient when a labor and delivery staff member rushes into the operating suite to say JE has just started tonic clonic seizures and has blood oozing from her IV site. What should you do at this point in time?

INTRODUCTION & EPIDEMIOLOGY Cardiopulmonary arrest is the final pathway in many life-threatening diseases. Sudden cardiac death results in 600,000 deaths annually in the United States. The rate of cardiac arrest in pregnancy appears to have increased and is now estimated to occur in one in 20,000 pregnancies.1

About 50 percent of maternal deaths are due to acute potentially treatable causes. Approximately 50 percent of maternal mortality can be assigned as preventable, and could be impacted to some degree by the health care system.2 Although this is not a daily occurrence, the prudent clinician is skilled in the techniques of cardiopulmonary resuscitation (CPR), which includes basic life support (BLS) and advanced cardiac life support (ACLS). Providers must be familiar with the underlying diseases leading to arrest—both those unique to pregnancy and those present in the general population. Furthermore they must understand the aspects of maternal physiology that influence resuscitative efforts and the evaluation and management of trauma in pregnancy. Fetal outcome is directly related to the well being of the mother.

— Chapter K: Mataernal Resuscitation and Trauma — 1 ETIOLOGY AND DIFFERENTIAL DIAGNOSIS Maternal resuscitation may be required as a result of pregnancy specific conditions, conditions not specific to pregnancy, or trauma. Providers should be familiar with pregnancy-specific diseases and procedural complications. Providers should try to identify these potentially reversible causes of cardiac arrest in pregnancy during resuscitation attempts.2 This section will therefore first examine causes of cardiopulmonary arrest unique to pregnancy, including amniotic fluid embolism, magnesium toxicity, preeclampsia/eclampsia, and postpartum hemorrhage. Next, causes of cardiopulmonary arrest that are not limited to pregnancy, including acute coronary syndrome (ACS), cerebrovascular accident (CVA), aortic dissection, and pulmonary embolism are reviewed. Table 1 summarizes the conditions that may be associated with cardiopulmonary arrest. Finally trauma is reviewed at the conclusion of the chapter.

Table 1: Obstetric and Nonobstetric Causes of Cardiac Arrest in pregnancy

Non-obstetric Causes • Anesthesia complications • Aortic Dissection • Bleeding (non-uterine) • Cardiac Disease (Acute Coronary Syndrome, myocardial infarction) • Cerebrovascular Accident • Disseminated Intravascular Coagulopathy • Sepsis • Thromboembolism Obstetric Causes • Amniotic Fluid Embolism • Eclampsia • HELLP • Magnesium toxicity • Postpartum Hemorrhage • Preeclampsia • Uterine Atony • Peripartum cardiomyopathy Adapted from: Vanden Hoek TL, Morrison LJ, Shuster M, et al. Part 12: Cardiac arrest in special situations: 2010 American Heart Association Guidelines for Cardiopulmanary Resuscitation and Emergency Cardiovascular Care,” Circulation. 2010; 122(18) sup 3:S829-S861. 2010 Cantwell R, Clutton-Brock, T, Cooper G, et al. Saving Mother’s Lives: reviewing maternal deaths to make motherhood safer: 2006-2008. The Eighth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom,” BJOG. 2011; 118:1-203. Campbell TA, Sanson TG. Cardiac Arrest and pregnancy. J Emerg Trauma Shock. 2009 Jan-Apr; 2(1): 34-42.

2 — — Chapter K: Maternal Resuscitation and Trauma Amniotic fluid embolism: Historically this has been thought to be a hypersensitivity reaction to fetal or amniotic fluid antigen in the maternal circulation. Though the trigger is not certain, during labor or other procedure, amniotic fluid or some other fetal substance enters the maternal circulation and triggers a massive anaphylactic reaction, activation of the complement cascade, or both. Initially, the combination of pulmonary artery vasospasm, pulmonary hypertension, and elevated right ventricular pressure cause hypoxia. Hypoxia leads to myocardial and pulmonary injury, left heart failure, and acute respiratory distress syndrome. Subsequent manifestations of this syndrome are massive hemorrhage with uterine atony and disseminated intravascular coagulopathy (DIC). Clinicians have reported successful use of cardiopulmonary bypass and treatment with activated factor VIIA to treat for coagulopathic bleeding, for women with life-threatening amniotic fluid embolism during labor and delivery.3 This condition is discussed further at the end of the chapter. Pre-eclampsia/eclampsia: Develops after the 20th week of gestation and can produce severe hypertension and ultimate diffuse organ system failure. If untreated it may result in maternal and fetal morbidity and mortality. This spectrum of diseases is addressed in a separate chapter (Chapter B - Medical Complications of Pregnancy). Excess magnesium sulfate: Iatrogenic overdose is possible in women with pre-eclampsia/ eclampsia who receive magnesium sulfate, particularly if the woman becomes oliguric. Cardiac and pulmonary manifestations include respiratory depression, prolonged atrio-ventricular conduction, complete heart block, and cardiac arrest. Administration of calcium gluconate (1 ampule or 1 g) is the treatment of choice for magnesium toxicity. Empiric calcium administration may be lifesaving.4 Postpartum hemorrhage: Accounts for a large percentage of maternal death and is treated in a separate chapter. (Chapter J – Postpartum Urgencies) Remember the Four T’s (tone, trauma, tissue, thrombin) and invisible hemorrhage (uterine rupture). Aortic dissection/pulmonary embolism/stroke: Pregnant women are at increased risk for spontaneous aortic dissection, life threatening pulmonary embolism and stroke. The successful use of fibrinolytics for a massive, life-threatening pulmonary embolism and ischemic stroke, have been reported in pregnant women.1 Non-accidental trauma and drug overdose: Pregnant women are not exempt from the trauma and mental illnesses that afflict much of society. Intimate partner violence also increases during pregnancy; in fact, homicide and suicide are leading causes of mortality during pregnancy.2 Trauma is discussed in a separate section below. Medication errors that may have caused the arrest should be considered and new intravenous preparations should be reformulated for each medication. Acute coronary syndromes: Pregnant women may experience acute coronary syndromes, typically in association with other medical conditions. Because fibrinolytics are relatively contraindicated in pregnancy, percutaneous coronary intervention is the reperfusion strategy of choice for ST-elevation myocardial infarction.1

The same reversible causes of cardiac arrest that occur in nonpregnant women can occur during pregnancy.5 Increasingly, women are presenting for maternity care with serious medical problems including Type I diabetes, cystic fibrosis, hemoglobinopathies, steroid dependent asthma, congenital and acquired heart disease, and transplanted organs. Advanced reproductive technologies have made it possible for older women, and those with other medical conditions usually associated with infertility, to become pregnant. These demographic and condition-specific risk factors increase the likelihood of cardiopulmonary arrest.

— Chapter K: Mataernal Resuscitation and Trauma — 3 Cardiac disease has increased to become the leading cause of maternal deaths overall, exceeding the rates of death from sepsis, hypertension, thromobosis, and amniotic fluid embolism.6 In the United States between 1996 and 2006 the rate of hospitalization for postpartum patients with chronic heart disease tripled.7

MATERNAL PHYSIOLOGIC CHANGES IN PREGNANCY Cardiovascular Pregnancy is a high flow, low-resistance state. The uterine arteries lack autoregulation, so uterine perfusion decreases with any drop in maternal blood pressure. The uteroplacental vascular bed functions as a maximally dilated, passive, low resistance system so that uterine blood flow is determined by perfusion pressure. Management of cardiopulmonary arrest or trauma must balance the need for sufficient volume to preserve uteroplacental flow with the tendency of the capillaries to leak because of the pregnancy related reduction of oncotic pressure. As summarized in Table 2, these adaptations of pregnancy make the maternal-fetal unit susceptible to deleterious effects of ineffective circulation.

During pregnancy, 20 to 30 percent of the cardiac output flows to the uterus, compared to less than two percent when the woman is not pregnant. In addition, in a supine pregnant woman the uterus can compress the aorta and inferior vena cava enough to sequester up to 30 percent of the blood volume in the lower extremities. To achieve this same degree of compression of the vena cava, a surgeon would have to completely occlude the vessel manually. Delivery, or left uterine displacement (LUD), relieves aortocaval compression with an increase in cardiac output by 20 to 25 percent.8

The thorax is less compressible by external pressure because of the cephalad displacement of the abdominal contents, hypertrophied breasts, and the presence of the gravid uterus. Pregnant women with hemorrhage may lose 1200 to 1500 ml of their blood volume before exhibiting signs of hypovolemia.9 The clinician’s first indication of significant hemorrhage may be a non-reassuring fetal heart rate pattern. Fluid resuscitation is especially important in pregnancy. Maternal shock is associated with an 80 percent fetal mortality.10

Estrogen increases excitability in uterine muscle fibers and is thought to have a similar effect on cardiac excitability. Although catecholamine levels do not appear to change during pregnancy, estrogen increases sensitivity to them by increasing the number of myocardial alpha-adrenergic receptors. This effect may increase the propensity for supraventricular arrhythmias.11

Respiratory Progesterone increases tidal volume and respiratory rate, which increases the amount of expired carbon dioxide and decreases the amount of carbon dioxide dissolved in serum. This chronic hyperventilation results in a compensated respiratory alkalosis with a deceased serum bicarbonate. During pregnancy, maternal apnea is associated with rapid declines in arterial pH and PaO2. These changes result in decreased buffering capacity compared to the non-pregnant state and make the pregnant patient more susceptible to organ damage from hypoventilation and hypoxia due to greater levels of acidosis. As obesity increases in our population, challenges to successful CPR will increase because of difficulty with intubation and chest compression.

4 — — Chapter K: Maternal Resuscitation and Trauma Chronic hypocapnia (PaCO2 of less than 30 mm Hg) is common in late pregnancy. Therefore a PaCO2 of 35 to 40 mm Hg, within the normal range for non-pregnant adults, is abnormal in pregnancy and may indicate impending respiratory failure. Oxygen consumption is increased in pregnancy, hence maintenance of arterial oxygenation is especially important in the resuscitation.

The pregnant patient has decreased functional residual capacity and functional residual volume, but increased tidal volume and minute ventilation. There will be a need to tailor ventilatory support due to these pregnancy associated metabolic changes.

Fetal oxygen requirements: The fetus of an apneic and pulseless mother has two minutes or less of oxygen reserve because the oxygen tension in the umbilical vein is always less than the uterine vein. The chances for a successful resuscitation of the mother or fetus decrease after four minutes. Therefore the clinician has four minutes to affect the return of spontaneous maternal circulation (ROSC) before she/he must begin dramatic action, hence the “four minute rule.”12,13

The best survival rate for the infant occurs when the infant is delivered no more than five minutes after the mother’s heart stops beating.12,14 The American Heart Association’s (AHA) goal is to achieve delivery by five minutes.1,15,16 Typically this requires that the provider begin the hysterotomy about four minutes after maternal cardiac arrest.1,15,16

Table 2. Physiologic Changes of Pregnancy that Effect Resuscitation

Cardiovascular Effect Increased Plasma volume by 40 to 50 percent, but Dilutional anemia results in decreased erythrocyte volume by the only 20 percent oxygen carrying capacity Cardiac output by 40 percent Increased CPR circulation demands Heart rate by 15 to 20 beats per minute Increased CPR circulation demands Clotting factors susceptible to thromboembolism Dextrorotation of the heart Increased EKG left axis deviation Estrogen effect on myocardial receptors Supraventricular arrhythmias Decreased Supine blood pressure and venous return Decreases cardiac output by 30 percent with aortocaval compression Arterial blood pressure by 10 to 15 mm Hg Susceptible to cardiovascular insult Systemic vascular resistance Sequesters blood during CPR Colloid oncotic pressure (COP) Susceptible to third spacing Pulmonary capillary wedge pressure (PCWP) Susceptible to pulmonary edema Respiratory Effect Increased Respiratory rate (progesterone-mediated) Decreased buffering capacity Oxygen consumption by 20 percent Rapid decrease of PaO2 in hypoxia Tidal volume (progesterone-mediated) Decreased buffering capacity Minute ventilation Compensated respiratory alkalosis Laryngeal angle Failed intubation Pharyngeal edema Failed intubation Nasal edema Difficult nasal intubation Decreased Functional residual capacity by 25 percent Decreases ventilatory capacity Arterial PC02 Decreases buffering capacity Serum bicarbonate Compensated respiratory alkalosis

— Chapter K: Mataernal Resuscitation and Trauma — 5 Gastrointestinal Effect Increased Intestinal compartmentalization Susceptible to penetrating injury Decreased Peristalsis, gastric motility Aspiration of gastric contents Gastroesophageal spincter tone Aspiration of gastric contents Uteroplacental Effect Increased Uteroplacental blood flow by 30 percent Sequesters blood in CPR of cardiac output Aortocaval compression Decreases cardiac output by 30 percent Elevation of diaphragm by 4 to 7 cm Aspiration of gastric contents Decreased Autoregulation of blood pressure Uterine perfusion decreases with drop in maternal blood pressure Breast Effect Decreased Chest wall compliance secondary to breast Requires increased CPR compression force hypertrophy Renal/Urinary Effect Increased Compensated respiratory alkalosis Decreases buffering capacity and increases acidosis during CPR Ureteral dilation, especially right side Interpretation of radiographs Decreased Bladder emptying Interpretation of radiographs

RESUSCITATION IN PREGNANCY The following discussion includes an overview of the principles of BLS and ACLS but presumes a familiarity with the AHA algorithms and CPR.16,17 In 2010 the AHA changed the sequence of BLS steps from ‘airway — breathing — circulation’ (A-B-C) to ‘circulation - airway – breathing’ (C-A-B). ACLS in-hospital providers should tailor the sequence of rescue actions to the most likely cause of arrest.17 Modifications of technique due to changes in maternal physiology are suggested. (Table 3)1,15

The initial resuscitative maneuvers are the same regardless of pregnancy status and are referred to as the BLS Algorithm:16,17 • Check responsiveness • Activate the emergency response system/Get automated external defibrillator (AED) • Circulation: check carotid pulse • Defibrillation Adult basic non-pregnant CPR should include:18 Chest compressions • providing chest compressions of adequate rate (at least 100/minute) • providing chest compressions of adequate depth • a compression depth of at least two inches (5 cm) • allowing complete chest recoil after each compression • minimizing interruptions in compressions • avoiding excessive ventilation Airway and ventilation • Deliver ventilations at a regular rate one breath every six to eight seconds (8 to 10 breaths/minute) and chest compressions can be delivered without interruption. • If multiple rescuers are available, they should rotate the task of compressions every two minutes. The above recommendations should be modified to allow for the changes in maternal anatomy and physiology. [See Modifications for Pregnancy (below), Table 2, Table 3, Figure 1]

6 — — Chapter K: Maternal Resuscitation and Trauma Table 3. Possible Modifications of Resuscitative Efforts in Pregnancy/Special Circumstances

Basic Life Support (BLS) Action Rationale Manual uterine displacement, 30 degree Decreases aortocaval compression left lateral tilt Increase chest wall compression force Decreased chest wall compliance with breast hypertrophy and diaphragmatic elevation Use cricoid pressure, if assistance is available Decreases gastric aspiration Perform compressions higher on sternum Elevated diaphragm and abdominal contents (slightly above center of sternum) Defibrillation: remove fetal or uterine monitors Loss of adequate cardiac shock dose, produced skin burns at monitor sites Heimlich maneuver = chest thrust Enlarged uterus displaces diaphragm Advanced Cardiac Life Support (ACLS) Action Rationale Early tracheal intubation, use short Difficult ventilation with pharyngeal edema, laryngoscope handle and smaller endotracheal tube breast hypertrophy, diaphragmatic elevation Consider other etiologies, eg., magnesium toxicity Tocolytic therapy Consider left wide paddle, adhesive pad, Dextrorotation of heart, breast hypertrophy or breast displacement Verify endotracheal tube with CO2 detector Esophageal detector more likely to not re-inflate after a compression Ventilation volumes and rates altered Tailor ventilatory support to oxygenation and ventilation Emergency hysterotomy after four minutes Decreases aortocaval and venous compression Remove both internal and external monitors Clear patient for defibrillation Place IVs above the diaphragm Avoid aortocaval and venous compression

No Change Defibrillation regimen Early return of effective maternal circulation Pharmacologic therapy Early return of effective maternal circulation

— Chapter K: Mataernal Resuscitation and Trauma — 7 Figure 1. Cardiac Arrest in the Pregnant Patient

• Activate cardiac arrest team • Lay patient in supine position and manually displace the uterus leftward or perform left lateral tilt of 27 to 30° • Begin chest compressions higher on the sternum • Use 100% oxygen when ventilating – secure airway early in the resuscitation. • Remove both fetal and/or uterine monitors • Give typical ACLS drugs and doses Entire Team Should Prepare for Possible Emergency Cesarean Delivery • If no return of spontaneous circulation (ROSC) after four minutes of resuscitation, consider cesarean delivery • Delivery should occur within five minutes of the beginning of the resuscitation

If BLS is not successful, then begin the ACLS Algorithms:1,16,17 • Airway: early use of advanced airway • Breathing: assist with ventilation and oxygen supplementation • Circulation: chest compressions higher on sternum • Defibrillation (Figure 2)

The above recommendations and other modifications (See Modifications for Pregnancy below), allow for the changes in maternal anatomy and physiology. Table 2, Table 3, Figure 1

Figure 2 outlines the AHA Cardiac Arrest Algorithm.1,16,17 Further discussion of other clinical scenarios are available from the AHA, e.g., bradycardia, tachycardia, pulmonary edema, acute MI, hypothermia, and acute stroke.

COMPLICATIONS OF CPR/RESUSCITATION Pregnant women are more susceptible to rib fractures and other iatrogenic injuries including liver lacerations and pneumothorax. Hence, a high index of suspicion is warranted looking for any of these complications. In the face of underlying toxemia, thrombocytopenia may predispose to bleeding and hematomas of the liver.

8 — — Chapter K: Maternal Resuscitation and Trauma Figure 2. Adult Arrest Algorithm, American Heart Association

— Chapter K: Mataernal Resuscitation and Trauma — 9 MODIFICATIONS OF CPR IN PREGNANCY As summarized in Table 2, many unique aspects of maternal physiology influence the conduct of resuscitative maneuvers in pregnancy. In order to prevent aortocaval compression by the uterus after 20 weeks, the uterus should be moved off the aorta, vena cava, and pelvic great vessels. The chest compression force at an angle of 27 degrees of left tilt is 80 percent. Tilt angles over 30 degrees are associated with the patient sliding off a raised surface and are difficult to achieve effective compression; 30 degree angle is desirable.19 (Figure 3)

Figure 3. Left Tilt for Uterine Displacement

30 DEGREE TILT IMAGE FROM THE SLIDE

It is important to ensure that the forces of the chest compressions are directed toward the spine and not just vertically downward.20 The latter causes lateral pressure in patients that are in a lateral tilt position, and hence less effective CPR circulation.19 A mechanical wedge (the Cardiff wedge), may be available for use in specialized, controlled settings.

MANUAL LEFT UTERINE DISPLACEMENT (LUD) In a systematic review it was noted that chest compressions were less forceful when a patient was in full-body left lateral tilt compared to the supine position.21 Furthermore, manual LUD has been found to reduce the incidence of hypotension and ephedrine requirements when compared to 15o degree left-lateral tilt in patients undergoing routine cesarean delivery.22

Manual LUD provides an alternative technique for aortocaval decompression, whereby at the same time the patient can remain supine and receive concurrent higher quality chest compressions while not delaying the onset of effective chest compressions by a need to facilitate a total body tilt. Manual LUD may also allow for easier delivery of defibrillation, IV access, and intubation. Two common methods include the two handed technique (Figure 4) and the one handed technique (Figure 5).

10 — — Chapter K: Maternal Resuscitation and Trauma Figure 4. Two Handed Manual Left Uterine Displacement Technique

Figure 5. One Handed Manual Left Uterine Displacement Technique (to come)

Several methods can be utilized to improve the effectiveness of chest compressions: 1. Place intravenous bags, rolled up towels under the right flank and hip, or full backboard (Figure 3) 2. Place the knees of a second rescuer under the right flank and hip, 3. Manually provide LUD, e. g., displace the uterus leftward (Figures 4 and 5) 4. Chest compressions more cephalad on sternum 5. Emergency hysterotomy (cesarean delivery)

Despite all the maneuvers, CPR in pregnancy should NOT be considered effective circulation, even with the necessary positioning, hence the need to relieve the aortocaval compression. (Figure 1) If there has not been ROSC by four minutes of ACLS, then aim for delivery by emergency hysterotomy within 5 minutes of resuscitative efforts.1,16 (See Table 10)

— Chapter K: Mataernal Resuscitation and Trauma — 11 TRAUMA IN PREGNANCY Trauma complicates one in 12 pregnancies, and is the leading non-obstetric cause of death among pregnant women.23-26 The most common traumatic injuries to pregnant women are: motor vehicle collisions (48 percent), assaults (17 percent), including intentional [suicides (3.3 percent), intimate partner violence, homicide, gunshot wounds (4 percent)] and non-intentional injuries, falls (25 percent), poisonings, and burns (2.7 percent).26,27 Nine out of 10 traumatic injuries during pregnancy are minor. However, 60 to 70 percent of fetal losses are a result of minor injuries.27 Trauma can also be divided into minor and major trauma. Minor trauma (e.g. a cut to the arm, or a twisted ankle without a fall) does not involve the abdomen/uterus, rapid compression, deceleration or shearing forces, and the patient does not report pain, vaginal bleeding, loss of fluid and has good fetal movement.28

Physicians, regardless of their involvement in intrapartum care, frequently see pregnant women in the emergency department, urgent care, or in their offices with minor accidents, falls or motor vehicle accidents. These physicians should be aware of the differences in CPR for pregnant patients and the technique of perimortem cesarean delivery for pregnant patients in cardiopulmonary arrest.

This section includes a review of the anatomic and physiologic changes of pregnancy important in evaluating and treating pregnant trauma victims. The evaluation and treatment of major trauma will be reviewed, and an evaluation protocol for pregnant women who suffer blunt abdominal trauma and falls is offered. This section concludes with a review of injuries sustained by pregnant women in motor vehicle crashes and from assault.

Anatomy and Physiology Relating to Trauma Many anatomic and physiologic changes of pregnancy relate to the occurrence, diagnosis, and management of trauma.9,26,29 During the first trimester, the thick walled uterus is well protected from trauma by the pelvic girdle. In the second trimester, relatively abundant amniotic fluid volume protects the fetus. By the third trimester, the now thin-walled and prominent uterus is subject to potential blows, penetration, or rupture. As the pregnancy approaches term, the relative fluid volume is decreased, which reduces the cushioning effect around the fetus. The fetal head at this point in gestation is usually protected within the bony pelvis.

The placenta is an inelastic organ attached to an elastic organ (the uterus). Accelerations or decelerations may deform the uterus and shear the placenta off of its implantation site, creating an abruption. The risk of abruption is independent of the placental location.

Gastrointestinal: Gastric emptying time is prolonged during pregnancy. As such, the clinician should always assume the stomach of a pregnant patient is full. Early gastric tube decompression should be considered. The intestines are relocated to the upper part of the abdomen and may be shielded by the uterus. Signs of peritoneal irritation, such as distention, rebound tenderness, guarding, and rigidity are frequently detected on examination after trauma, but may be less pronounced during pregnancy.

Urinary: Renal blood flow and the glomerular filtration rate are increased in pregnancy. Blood urea nitrogen and serum creatinine levels are decreased. Glycosuria is common, due to a lowered threshold of excretion. There may be bilateral or unilateral hydronephrosis with ureteral dilation. These changes may affect interpretation of lab and x-ray studies in trauma.

12 — — Chapter K: Maternal Resuscitation and Trauma MAJOR TRAUMA When major trauma occurs in pregnancy, evaluation and treatment of the mother is the first priority. This approach also serves the best interests of the fetus. The diagnosis and management of the pregnant woman who has experienced major trauma does not differ significantly from the care of a non-pregnant trauma victim, except for recognition of, and adjustment for, the anatomic and physiologic changes of pregnancy. The Advanced Trauma Life Support, Student Course Manual (9th Edition)9 outlines this Trauma Primary Survey: A Airway maintenance with cervical spine protection B Breathing and ventilation C Circulation with hemorrhage control D Disability: neurologic status E Exposure/Environmental control: Completely undress the patient, but prevent hypothermia

The Trauma Primary Survey of resuscitation hold true in pregnancy and are, in fact, more important because of the risks to the fetus from maternal hypotension and hypoxia.

The Primary Maternal Survey (Table 5) addresses life support and resuscitation. Fluid resuscitation should be pursued very aggressively.29 A pregnant patient can lose a significant amount of her blood volume before she demonstrates hypotension and other signs of shock. Crystalloid and early type-specific packed red blood cells are indicated to restore the physiologic hypervolemia of pregnancy. The mother should be returned to the left lateral position after a thorough physical exam.

Table 5. Primary Maternal Survey

• Patent airway • Adequate ventilation and oxygenation • Effective circulatory volume • Fluid support • Blood replacement

The primary fetal survey (Table 6) is pursued after initial assessment and stabilization of the mother. The major diagnostic details relating to the fetal primary survey are: fetal viability and well-being, likelihood of fetal injury and feto-maternal transfusion, gestational age, abruption, premature labor, rupture of membranes, presentation and uterine rupture.

Table 6. Primary Fetal Survey

• Fundal height • Uterine activity • Fetal heart rate pattern and movement • Assess for vaginal bleeding • Assess for ruptured membranes • Assess cervix for dilation and effacement

The maternal secondary survey (Table 7) is not different from non-pregnant patients. Indications for abdominal computed tomography (CT), focused assessment sonography in trauma (FAST), and diagnostic peritoneal lavage (DPL) have the same indications as in non-pregnant patients. If DPL is performed, the catheter should be placed above the umbilicus, using an open technique. Indicated x-ray

— Chapter K: Mataernal Resuscitation and Trauma — 13 studies can be performed without concern for radiation injury to the fetus, as the immediate diagnostic benefits far outweigh any theoretical risk to the fetus.30 However, shielding the fetus and minimizing exposure is prudent when possible.

The use of abdominal ultrasound by a skilled operator should be considered in detecting pregnancy and possible causes of the cardiac arrest, but this should not delay other treatments. Ultrasound provides fetal assessment, e.g., amniotic fluid volume, fetal presentation, estimated gestational age, and is occasionally helpful in cases of anterior abruption. Pelvic examination can be performed after documentation of placental location.

Table 7. Secondary Maternal Survey

• X-rays • Focused assessment sonography in trauma • Diagnostic peritoneal lavage • Central venous pressure (CVP) • Urine output • Baseline laboratory to include: o Serum bicarbonate o Kleihauer Betke o Coagulation factors with fibrinogen level

Laboratory testing of severely injured patients should include the same tests done for non-pregnant patients. Monitoring with a central venous pressure line can be extremely helpful, as is measuring the urine output. Coagulopathy can accompany abruption, amniotic fluid embolism, and other obstetric events relating to trauma, so measurement of fibrinogen, platelet count, and fibrin split products (D-Dimer) are recommended. The fibrinogen level may double in late pregnancy. A normal fibrinogen level may indicate early disseminated intravascular coagulation (DIC) which can be seen with abruptio placenta.9

Definitive Care: Certain maternal injuries, such as visceral injury or retroperitoneal hemorrhage, require immediate surgery to save the life of the mother and the fetus. Uterine rupture and abruption threaten the baby more directly. Uterine rupture manifests by signs of hypovolemia and hemoperitoneum. The fetus will often be acidotic or dead, and may appear on x-ray or ultrasound exam with extended limbs or in a bizarre position. Abruption presents with classical signs: contractions, rigid and tender uterus, expanding uterine height, vaginal bleeding, non reassuring fetal heart rate tracing or demise, and coagulopathy. Both conditions require surgery for mother and fetus alike.

Appropriate imaging studies should not be avoided due to the presence of the fetus. Typically concerns about ionizing radiation and fetal harm begin somewhere between 5,000 and 10,000 milirads, or 5 to 10 rads.29,30 The average CT scan of the abdomen and pelvis is in the order of 2 to 2.5 rads.

After management of the primary trauma survey, two large bore intravenous catheters should be placed and supplemental oxygen administered to maintain a saturation of greater than 95 percent. Aggressive transfusion of blood products may provide volume and improve oxygen carrying capacity.9 The use of pressors should be avoided until adequate volume replacement has been completed. The uterus should be displaced from the vena cava and aorta. Following maternal stabilization, the secondary maternal and fetal survey can be completed.

14 — — Chapter K: Maternal Resuscitation and Trauma Fetal injuries are highly variable. Skull and brain injuries are common when the maternal pelvis is fractured and the fetal head is engaged. Fetal contrecoup injuries may occur. Penetrating injuries may be present from gunshot or knife attacks. Although penetrating injuries have a lower mortality in pregnancy, the fetal morbidity and mortality is significantly higher.25 This may occur because the gravid uterus is acting as a ‘shield’ to the maternal organs. Maternal mortality from penetrating wounds is less than four percent in pregnancy.25 On the other hand, 60 to 90 percent of stab or gunshot wounds to the abdomen result in fetal injury or death.31 Surgical exploration of the maternal abdomen is almost always necessary in cases of penetrating abdominal injury.

Routine administration of Rh Immune Globulin is indicated for unsensitized Rh negative women with significant abdominal trauma. Indications for tetanus prophylaxis do not change in pregnancy and appropriate candidates should be vaccinated.

The Kleihauer Betke (KB) assay should be considered on patients following significant blunt uterine trauma, regardless of Rh status, in order to assess the degree of fetomaternal hemorrhage.32-36 In pregnant trauma patients with an Injury Severity Score > 2 (Appendix 1), a positive KB is an effective predictor of adverse perinatal outcomes, particularly with more severe trauma.37,38

The mean estimated blood volume of injected fetal blood is usually less than 15 ml, and in more than 90 percent of patients, is less than 30 ml. One amp of Rh immune globulin, which is 300 ug, will cover a 15 ml red blood cell hemorrhage, or 30 ml total blood volume hemorrhage. Serial testing may be appropriate to assess ongoing hemorrhage.

Unfortunately the Kleihauer Betke assay is often not available in a timely fashion for acute clinical management. Fetal heart monitoring, uterine tocographic monitoring, or ultrasound evaluation may be more useful in the acute setting. An alternative approach has been suggested to expedite therapy by calculating the total blood volume of a fetus.39 First estimate the fetal weight by ultrasound, then multi- ply the estimated fetal weight in kilograms by the total blood volume of a fetus (approximately 100 cc/ kg) to determine the maximum total dose of Rh immune globulin.39 Each 300 mcg Rhogam vial will cover a 30 cc total blood loss, so two vials would cover the total fetal blood loss for a 600 gram fetus. In the case of a 3.5 kg fetus, 3.5 kg times 100 cc/kg would produce an estimated total fetal blood volume of 350 cc. This approach will overestimate the maternal exposure to fetal blood since only a limited amount of fetal blood usually will enter maternal circulation even in severe trauma.39

Emergency hysterotomy (cesarean delivery) may be required for several reasons. It may be difficult to treat the maternal condition around the gravid uterus; or the obstetric pathology contributes to the patient’s worsening condition (as in abruption with coagulopathy); or the fetus is acidotic. Emergency hysterotomy may improve the mother’s status, but may increase her risk of hypovolemia. After 23 to 24 weeks gestation emergency hysterotomy may save the fetus, the second life at risk.

MINOR TRAUMA The most common trauma-related occurrence among pregnant women is a minor trauma, such as a fall, minor MVC, or blunt abdominal trauma, which cause little or no maternal injury. In minor cases, the clinician must often make a judgment about the necessity of examination or monitoring. Erring on the side of caution is recommended to alleviate anxiety and because of cases in which seemingly insignificant trauma has resulted in fetal injury or demise. Abruption usually becomes apparent shortly after injury, fetal monitoring in women who experience trauma beyond 20 weeks gestation should be

— Chapter K: Mataernal Resuscitation and Trauma — 15 initiated as soon as the patient is stabilized. The patient should be monitored by cardiotocograph for a minimum of four hours but may be extended to a six hour minimum.9,32 In 100 percent of patients found subsequently to have a placental abruption, eight or more contractions per hour were present in the first four hours.40

Monitoring should be continued for a minimum of 24 hours if there is presence of six uterine contractions per hour26,41 non reassuring fetal heart rate patterns, vaginal bleeding, significant uterine tenderness, serious maternal injury or rupture of membranes occurs during the initial four to six hours monitoring period. If none of these concerning findings is present then the patient may be discharged with instructions to return if she develops vaginal bleeding, leakage of fluid, decreased fetal movement or severe abdominal pain.9,29 A guideline for managing minor trauma is presented in Table 8.

The presence of six uterine contractions per hour26,41 and fetal red blood cells in the maternal circulation are good indicators of fetal risk from abruption. Ultrasound has poor sensitivity (24 percent) for detection of abruptio placenta, however it is very specific (96 percent); resulting in a positive predictive value of 88 percent if abruption is seen on ultrasound and a negative predictive value of 53 percent if abruption is not seen.42

Table 8. Management of Blunt Trauma in Pregnancy • Primary maternal and fetal * Risk factors:9 Discharge criteria: survey • Maternal heart rate greater • Resolution of contractions • Lab: blood type, Rh, hematocrit. than 110 bpm • Reassuring fetal heart tracing Kleihauer Betke (KB) test; • Injury Severity Score • Intact membranes coagulation studies greater than nine • Consider obstetric ultrasound (Appendix I)43 • No uterine tenderness • If greater than 20 weeks, • Evidence of placental • Non vaginal bleeding monitor for contractions abruption • All Rh negative patients • If less than six contractions • Fetal baseline heart rate receive full dose (300 mcg) per hour and no risk factors*, greater than 160 bpm or Rh immune globulin monitor for six hours, then less than 120 bpm (more if indicated by KB) 9,26,41 discharge • Ejection during motor • If > 6 contractions per hour vehicle accident or risk factors*, monitor for • Motorcycle or pedestrian 24 hours collision

Documentation should be thorough, fact focused, and non-speculative in these emotionally and medicolegally charged scenarios.39 For example, patient involved in minor, low speed MVC, no abdominal trauma recalled, airbags did not deploy, etc. In one’s medical decision making, it may be helpful to acknowledge the lack of sensitivity of ultrasound for possible abruptio placenta. On the other hand, uterine tocodynamometry is noninvasive and over an appropriate period of observation, highly sensitive, though non-specific.32 A prospective cohort study called this approach into question by demon- strating no significant increase in adverse outcomes in the minor trauma during pregnancy cohort.44

16 — — Chapter K: Maternal Resuscitation and Trauma MOTOR VEHICLE COLLISIONS Motor vehicle collisions (MVC) accounted for 34,080 deaths and four million injuries in the United States in 2012 and are increasing.45 Two percent of pregnant women are involved in a MVC during their pregnancy.36 MVC produce a disproportionate number of fetal deaths, e.g., MVC 82 percent versus 6 percent gunshot wounds and 3 percent falls.46,47

Seat belted pregnant women sustain death and severe injury at a rate of about half that of women who are not seat belted. Seat belt use actually drops during pregnancy, because women fear that the seat belt will hurt the baby. In blunt trauma patients, the most common cause of fetal death is maternal death.40 Women may also fear being trapped by a seat belt in a fire or underwater submer- sion when, in fact, such incidents are rare. The dangers related to ejection from the vehicle, or secondary collision within the vehicle, are far greater than being trapped. In any event, a conscious and uninjured occupant is more likely to unfasten a seat belt and escape from a burning or submerged car than an unbelted, but severely injured, occupant. Seat belt use should be a major issue of prenatal counseling in every pregnancy.

Proper use of seatbelts may be the best predictor of maternal and fetal outcome. There is an 85 percent reduction in fetal morbidity and mortality, as well as serious fetal injury by wearing seatbelts.48 Incorrect seat belt use can contribute to intrauterine injury and fetal death.49 The lap belt should be placed as low as possible under the protuberant portion of the abdomen and the shoulder belt positioned off to the side of the uterus, between the breasts and over the midportion of the clavicle. Placement of the lap belt over the dome of the uterus significantly increases pressure transmission to the uterus and has been associated with significant uterine and fetal injury. There should not be excessive slack in either belt, and both the lap and shoulder restraints should be applied as snugly as comfort will allow. Airbag deployment reduces injury to pregnant women. Pregnant occupants are not at increased risk of adverse pregnancy outcomes while traveling in a vehicle that is equipped with an air bag and crashes.50 The American College of Obstetricians and Gynecologists (ACOG)51 and the National Highway Traffic and Safety Administration52 both recommend that pregnant women who are occupants in motor vehicles wear lap and shoulder seatbelts and not turn off air bags.

DIRECT ASSAULT Direct assault on the abdomen can be a regrettable manifestation of intimate partner violence. Abused women are a frequently undetected high-risk group. ACOG and the U.S. Preventive Services Task Force (USPSTF) recommends universal screening for intimate partner abuse.53-56 Every provider should be alert to this possibility and may, indeed, uncover battering when a patient presents with a vague or inconsistent history of trauma. Battering may escalate in pregnancy and the abdomen is the most frequent target for blows, kicks, and other assaults. Prenatal care should include a routine screening for intimate partner violence, and identified patients should be appropriately counseled and referred. In patients who have experienced intimate partner violence (IPV), an assessment for depression and suicidality should accompany assessment for immediate safety.57

Indicators that suggest the presence of intimate partner violence include: • Injuries inconsistent with the stated history • Diminished self image, depression, or suicide attempts • Self abuse • Frequent emergency department (ED) or provider’s office visits

— Chapter K: Mataernal Resuscitation and Trauma — 17 • Symptoms suggestive of substance abuse • Self blame for injuries • Partner insists on being present for interview and examination and monopolizes discussion

CASE SCENARIO: JE CONTINUED You immediately scrubbed out of the cesarean delivery you were assisting with and find JE has stopped the tonic clonic movements, but is now non-responsive to painful stimuli and in respiratory arrest. JE has a thready pulse at 180 bpm, blood pressure 40 over palpable. She is now oozing serous blood from all her recent venopuncture sites, as well as the IV site. While you are assessing JE, she becomes pulseless. You call for assistance and begin CPR with JE in 27 to 30 degrees of left lateral shift. You apply your chest compressions slightly above center of sternum. The patient is quickly intubated by a colleague from the emergency department, but JE does not respond to resuscitative efforts within four minutes.

You are a maternity provider without privileges to perform cesarean delivery as the primary surgeon. The only cesarean delivery provider in your small rural hospital is still operating on a patient under general anesthesia and will be unavailable for the next 20 minutes.

What should do you do next?

SPECIAL TECHNIQUE: EMERGENCY HYSTEROTOMY (CESAREAN DELIVERY) Historically, perimortem cesarean delivery was performed to give birth to an infant whose mother was dead to facilitate separate burials for the mother and infant. Emergency hysterotomy has re- emerged as a procedure to be performed after maternal cardiac arrest to increase the survival of the mother and fetus.12,13 The AHA recommends that if there has not been ROSC by four minutes of Advanced Cardiac Life Support (ACLS), then aim for delivery by emergency hysterotomy within five minutes of resuscitative efforts.1,15,16

Emergency hysterotomy is indicated when: • Personnel with appropriate skill and equipment to perform the procedure are involved, • The mother fails to respond with a return of spontaneous circulation within four minutes, • The mother is known to be at least 20 weeks gestation or there is an obviously gravid uterus* • Appropriate facilities and personnel are available to care for the mother and infant after the procedure. (Table 9)

*An obviously gravid uterus (i.e. at last 20 week size or fundal height above the umbilicus) can be assumed to cause aortocaval compression and maternal benefit is anticipated with delivery of the fetus.1,15,16 Fetal benefit occur when gestational age reaches fetal viability at 23-24 weeks.

18 — — Chapter K: Maternal Resuscitation and Trauma Table 9. Emergency Hysterectomy (Cesarean Delivery) Decision Factors to Consider Upton Maternal Arrest Key Factors Response Teams • Immediate and effective communication that an emergency is occurring. • Aware of the fastest routes to the L&D unit, EM Dept and all ICU’s. • Closed loop communication during the resuscitation. • Assignment of roles, detailed scriber with times. Code leader should be an individual with knowledge of the management of pregnant patients who is not task saturated, can communicate effectively and periodically reassess management goals and outcomes. • Is hysterotomy within the rescuer’s skill comfort zone? Maternal Factors • Mother is receiving appropriate BLS and ACLS care? • Has the mother responded to any arrest interventions? • Are there any reversible causes for the arrest? Infant Factors • Is the fetus old enough to survive? Fetal viability is estimated at 24 to 25 weeks. • What is the status of the fetus at the time of the mother’s arrest? Key Interventions Response Teams • Are appropriate equipment and supplies available? The most important item is a scalpel, perimortem cesarean delivery must not be delayed while waiting for a cesarean tray. • Are skilled neonatal support personnel available? • Immediately prepare for postmortem cesarean at first recognition of maternal arrest. Maternal Factors • Left uterine displacement to relieve aortocaval compression (ACC). • CPR with hands slightly higher on the sternum with compression depth of at least 2 inches. One hundred compressions per minute, changing compressors every two minutes (DO NOT STOP CHEST COMPRESSIONS EXCEPT FOR DEFIBRILLATION). • Intubation early, oxygen at 100%. Increased risk for pregnancy related complications in airway management. • Defibrillate according to AHA guidelines. • Administer medications intravenously above the diaphragm. • Continue CPR throughout and strive to make an incision at four minutes in order to deliver fetus at five minutes after the start of cardiac arrest. Infant Factors • Neonatal survival may be greatest (if past viability at 24 to 25 weeks) when the fetus is delivered within five minutes.

The best fetal survival rates are obtained when emergency hysterotomy is performed within five minutes of ineffective maternal circulation. There was 98 percent intact neurologic status in a cohort of 45 surviving infants delivered within five minutes of maternal death but this decreased to 33 percent of the nine infants surviving a delivery that occurred 16 to 25 minutes after maternal death.58 It may still be worthwhile to pursue delivery after this period, as fetal mortality is 100 percent if no action is taken. Some infants have survived up to 20 to 30 minutes after ineffective circulation.12,13

Despite the recommendation for rapid initiation of hysterotomy there are rare documented cases of intact fetal survival as long as thirty minutes after maternal death as demonstrated by a recent case report of a woman who jumped out of a fourth floor window while in labor and a perimortem cesarean was performed thirty minutes after death was confirmed.59

— Chapter K: Mataernal Resuscitation and Trauma — 19 A systematic review found that the predictors of maternal survival for those patients undergoing emergency hysterotomy were in-hospital location arrest and hysterotomy occurring less than 10 minutes after maternal arrest.60

With emergency hysterotomy, maternal survival increases because removal of the fetus results in an improvement in maternal circulation during CPR. In 12 of 22 cases women had sudden and often profound improvement, including return of pulse and blood pressure at the time the uterus was evacu- ated.12 Uterine evacuation during emergency hysterotomy at term can raise cardiac output by about 20 to 25 percent by relieving aorto-caval compression. When there is an obvious gravid uterus, the emergency cesarean delivery team should be activated at the onset of the maternal cardiac arrest.1

Emergency hysterotomy (See Chapter Q — Cesarean Delivery — Surgical Procedure) should not be delayed while attempting to listen for fetal heart tones or perform an ultrasound study to document gestational age. Omission of an emergency hysterotomy, or delay in performing the procedure, may lead to the unnecessary loss of two lives, though the decision is multi-dimensional. (Table 9) In a randomized simulation setting the total time to incision for perimortem cesarean delivery performed in the labor room was significantly faster than perimortem cesarean delivery performed after moving to the operating room.61 Personnel with the appropriate skill and equipment should provide this service, in or out of the hospital. (Table 10, Figure 1) An obviously gravid uterus is clinically deemed large enough to cause aortocaval compression which correlates to approximately 20 week size or a fundal height at or above the umbilicus1,15,16

Table 10. Steps in Performing an Emergency Hysterotomy

• Initiate immediate CPR and ACLS with lateral uterine displacement. • Initiate hysterotomy after four minutes of ineffective maternal circulation. • Attempt procedure with an obviously gravid uterus.* • Prepare equipment / personnel for emergency hysterotomy and neonatal resuscitation. Avoid delays for fetal heart tones or waiting for an obstetrician. • The first skilled physician available should initiate the hysterotomy. • Wear appropriate personal protective equipment to protect health personnel from transmission of infection. • Perform hysterotomy with a Joel-Cohen method or vertical midline skin incision, and a vertical uterine incision. (Refer to Chapter Q -Cesarean Delivery) Use modified sterile technique, e.g., ‘crash’. Give infant to attendant for drying and warming and/or resuscitation. • Pack the uterus with moist sponges. Remove lateral tilt. Continue ACLS throughout. • When hemodynamically stable, remove the placenta and close uterus with # 0 absorbable suture. Close anatomically, depending on available personnel and location. Obtain hemostasis with interrupted 0 absorbable suture.

*An obviously gravid uterus is clinically deemed large enough to cause aortocaval compression which correlates to approximately 20 week size or a fundal height at or above the umbilicus1,15,16

Consent from family members before performing the procedure is helpful, but not necessary. It is the responsibility of the health care provider to perform an emergency hysterotomy if the above criteria are met. As long ago as 1931, Campbell and Miller concluded that “a civil action for damages might follow for the negligence or the malpractice of the surgeon or physician in failing to follow the usual and customary practice” in regard to emergency hysterotomy.62 The surgical team should

20 — — Chapter K: Maternal Resuscitation and Trauma be prepared to care for the newborn infant. A newborn can lose 30 percent of the available energy reserve in the first five minutes in a cold moist environment, hence immediate drying and warming is indicated. Table 11 provides a list of instruments helpful to perform emergency hysterotomy.

If those instruments are not available, a scalpel to conduct the delivery and a blanket for the infant are the items that are immediately necessary. Antibiotic and wound management will be necessary if the mother survives. Avoid chaos. Perform practice drills with all clinical stakeholders.

Table 11. Emergency Hysterotomy Kit

OBSTETRIC SUPPLIES PEDIATRIC SUPPLIES Knife handle, #10 scalpel blade Neonatal blankets Bladder blade retractor Self inflating resuscitation bag: Infant, child Bandage and dissecting scissors Resuscitation masks: Neonate, infant Sterile laparotomy sponges DeLee suction trap Abdominal retractors Bulb syringe Heaney clamps Hemostats Ring forceps Cord clamps Needle holders Toothed and non-toothed dissecting Forceps or pickups 0 Chromic sutures One Vicryl sutures Sterile gloves

Some medical conditions indicate a need for simultaneous CPR and hysterotomy, e.g., mitral and aortic stenosis, cardiomyopathy, pericardial disease, core temperature less than 34 degrees Farenheit, pulmonary /cardiac injury or disease, and carbon monoxide poisoning. If the pregnant patient’s hemodynamic status is stabilized, then “the four minute rule” is not applicable. Restoration of maternal function sufficient to maintain the pregnancy, even if recovery is incomplete, may be of value for the fetus and the family. This is especially important the more remote from term the patient is. Even patients sustaining irreparable trauma deserve attentive assessment and institution of life support.

AMNIOTIC FLUID EMBOLISM Amniotic fluid embolism (AFE) is rare, with an estimated incidence of AFE is 1:15,200 and 1:53,800 deliveries in North America and Europe, respectively.63 In the past, the maternal mortality rate from this complication was initially estimated at 85 percent, with half of the deaths occurring in the first hour.64 With the advent of intensive care units, population-based data now suggests that the case fatality rate and perinatal mortality associated with AFE are 13 to 30 percent and 9 to 44 percent, in North America and Europe respectively.63 AFE remains one of the most catastrophic conditions that can befall the pregnant patient. AFE is a catastrophe for the fetus as well, with neurologically intact survival, in only 39 percent.64

Predisposing Factors & Pathophysiology Risk factors associated with an increased risk of AFE include advanced maternal age, placental abnormalities, operative deliveries, eclampsia, polyhydramnios, cervical lacerations, and uterine rupture.63 Since the first description of AFE in 1941 it has been thought of as a mechanical event in which a bolus of amniotic fluid enters the systemic circulation due to tetanic contraction, moves

— Chapter K: Mataernal Resuscitation and Trauma — 21 through the pulmonary circuit, produces a massive perfusion failure, bronchospasm and shock.65 The density of particulate matter in the fluid was felt to be related to the lethality of the event.

The number of cases failing to fit this picture led to a reconsideration of the pathophysiology, which suggests that the syndrome can occur with simple exposure to small amounts of amniotic fluid. A good case can be made to include AFE in a group of “anaphylactoid syndromes” occurring in late pregnancy or labor. Pathophysiologic studies suggest that left heart failure and pulmonary vasospasm are prime etiologic factors in cardiovascular collapse, but that the underlying mechanism may be an anaphylactic-like event with an associated 41 percent incidence of atopy or allergy.64 The hemodynamic response in AFE is biphasic, with initial pulmonary hypertension and right ventricular failure, followed by left ventricular failure.63 Disseminated intravascular coagulopathy is the most common complication, possibly due to the large amount of tissue factor in amniotic fluid.

CLINICAL PICTURE The clinical picture develops with stunning rapidity. The syndrome begins with respiratory distress (tachypnea and dyspnea) accompanied by restlessness, cyanosis, and sometimes nausea and vomiting. Seizures are common, occurring in 50 percent of women.66 Unexpected cardiovascular collapse occurs and profound DIC may follow. Finally, the patient goes into a coma and dies. In many cases, these events progress quickly so that only the most rudimentary diagnostic studies and resuscitative efforts can be made.

DIAGNOSIS Definitive diagnosis of this condition is generally made post-mortem. Clinical diagnosis relies primarily on clinical observations. If time permits, helpful laboratory values include blood gases and coagulation factors. The differential diagnosis includes other catastrophic causes of cardiopulmonary compromise, such as massive pulmonary embolism, bilateral pneumothorax, myocardial infarction, or gastric fluid aspiration. Obstetric conditions that mimic AFE include severe abruption, uterine rupture, inverted uterus and uterine atony. In specific circumstances, consider septic shock and eclampsia.

MANAGEMENT The management of amniotic fluid embolism is largely supportive. An aggressive medical approach seems justified and certainly can do no harm for the patients who survive the initial catastrophic event.

When an obstetric patient collapses unexpectedly, the BLS algorithm and then the appropriate ACLS algorithm should be attended to, with the airway secured and ventilation assured, using endotracheal intubation if necessary. Oxygen should be administered at 100 percent. Two large bore intravenous catheters should be placed and aggressive fluid replacement using crystalloid solution begun. Pressor agents, such as dopamine will likely be required. Blood should be drawn for complete hemogram, coagulation panel, and chemistry panel, including electrolytes and renal function. Arterial blood gases should be obtained. Urinary output should be monitored via indwelling catheter, and a portable chest x-ray and 12-lead electrocardiogram should be obtained. A cardiac monitor should be applied and ACLS initiated. Hemodynamic monitoring will probably be required, using an arterial access line and possibly a Swan-Ganz catheter.

22 — — Chapter K: Maternal Resuscitation and Trauma Coagulation factors should be assessed every two hours and blood component therapy initiated as needed with packed red cells, platelets (if the platelet count is less than 50,000), fresh frozen plasma, or cryoprecipitate. Given the possible anaphylactoid nature of the condition, epinephrine is theoretically useful. Positive end expiratory pressure is usually required to prevent alveolar collapse and to recruit atelectatic alveoli. Fluids, dopamine and furosemide should be administered based on hemodynamic parameters.

SUMMARY The rate of cardiac arrest in pregnancy appears to have increased and is now estimated to occur in one in 20,000 pregnancies.1 With 44 to 50 percent preventable maternal deaths, the next challenge will be to improve maternal mortality one pregnant patient at a time. CPR and ACLS modified for maternal physiology, prompt diagnosis, and emergency hysterotomy provide important tools to meet that challenge.17,18

Regardless of the cause of the maternal collapse, your facility should perform regular drills to assure that your entire labor and delivery staff is functioning with the same set of assumptions.67 Documentation should be thorough, but fact focused and non-speculative in these emotionally and medicolegally charged scenarios.39

SUMMARY OF RECOMMENDATIONS Category A Perimortem cesarean delivery should be performed in the labor room rather than relocating to the operating room.61

Category B Pregnant women who experience trauma beyond 20 weeks gestation should be monitored by cardiotocograph for a minimum of four hours.9,32

When there is an obvious gravid uterus, the emergency cesarean delivery team should be activated at the onset of the maternal cardiac arrest.1

Screen women of childbearing age for IPV, such as domestic violence, and provide or refer women who screen positive to intervention services.54-56

Screening for fetomaternal transfusion (e.g Kleihauer Betke) should occur in pregnant women who suffer significant blunt uterine trauma beyond 11 weeks’ gestation.32-38

Category C To relieve aortocaval compression during chest compressions and optimize the quality of CPR, it is reasonable to perform manual left uterine displacement.1,21

Emergency hysterotomy within four minutes of maternal cardiac arrest improves maternal and neonatal outcomes.1,13

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A prospective controlled for Experienced Providers: Manual and Resource Text, Chapter study of the outcome after trauma during pregnancy. Am J 18: Cardiac Arrest Associated with Pregnancy. 2013 Obstet Gynecol 1990;162:1502-10 16. Morrison LJ et al. 2010 International Consensus on 33. Barraco RD, EAST Practice Management Guidelines Work Cardiopulmonary Resuscitation and Emergency Cardiovascular Group. Practice management guidelines for the diagnosis Care Science With Treatment Recommendations Part 8: and management of injury in the pregnant patient: the EAST Advanced Life Support 2010 International Consensus on Practice Management Guidelines Work Group. J Trauma. 2010 Cardiopulmonary Resuscitation and Emergency Cardiovascular Jul;69(1):211-4. Care Science With Treatment Recommendations Circulation. 2010; 122: S345-S421 34. Rose PG, Strohm PL, Zuspan FP. Fetomaternal hemorrhage following trauma. Am J Obstet Gynecol. 1985 Dec 15;153(8):844-7 17. American Heart Association. Advanced Cardiac Life Support, Provider Manual, 2011 35. Muench MV, et al Kleihauer-betke testing is important in all cases of maternal trauma. J Trauma. 2004 Nov;57(5):1094-8. 36. Muench MV, Canterino JC. Trauma in Pregnancy. Obstet Gynecol Clin N Am 2007 34:555-583.

24 — — Chapter K: Maternal Resuscitation and Trauma 37. Trivedi N, et al Predicting adverse outcomes following trauma in 54. American College of Obstetricians and Gynecologists. Intimate pregnancy. J Reprod Med. 2012 Jan-Feb;57(1-2):3-8. partner violence. Committee Opinion No. 518. Obstet Gynecol 38. Melamed N, et al Pregnancy course and outcome following 2012;119:412–7. blunt trauma. Journal of Maternal-Fetal and Neonatal Medicine, 55. Moyer VA; U.S. Preventive Services Task Force. Screening for September 2012, Vol. 25, No. 9 : 1612-1617 intimate partner violence and abuse of elderly and vulnerable 39. ACOG Update Series: Major and minor trauma in pregnancy. adults: U.S. preventive services task force recommendation Vol. 35, No. 6 December 2009 Medical Information Systems statement. Ann Intern Med. 2013 Mar 19;158(6):478-86. Inc. 2 Seaview Blvd. Port Washington, New York. http://www. 56. U.S. Preventive Services Task Force. Screening for Intimate acogupdate.com/ Partner Violence and Abuse of Elderly and Vulnerable Adults: 40. Shah AJ, Kilcline BA Trauma in pregnancy. Emergency Recommendation Statement Am Fam Physician. 2013 Apr Medicine Clinics of North America 2003: 21:615-629 15;87(8):online. 41. Dahmus, MA, Sibai, BM. Blunt abdominal trauma: Are there 57. Cronholm PF, Fogarty CT, Harrison SL. Intimate Partner any predictive factors for abruption placentae or maternal-fetal Violence. Am Fam Physician. 2011;83(10):1165-1172. distress? Am J Obstet Gynecol 1993; 169:1054-9. 58. Whitty JE. Maternal Cardiac Arrest in Pregnancy Clin Obstet 42. Glantz C, Purnell L. Clinical utility of sonography in the diag- Gynecol 2002 45(2):377-392 nosis and treatment of placental abruption. J Ultrasound Med. 59. Capobianco G, Balata A, Mannazzu MC, Oggiano R, Pinna 2002 Aug;21(8):837-40. Nossai L, Cherchi PL, Dessole S. Perimortem cesarean delivery 43. Baker SP et al, “The Injury Severity Score: a method for 30 minutes after a laboring patient jumped from a fourth-floor describing patients with multiple injuries and evaluating emer- window: baby survives and is normal at age 4 years. Am J gency care”, J Trauma 1974 14:187196 Obstet Gynecol. 2008;198(1):e15-6. 44. Cahill AJ, Bastek JA, Stamillio DM, Odibo AO, Stevens E, 60. Einav S, Kaufman N, Sela HY. Maternal cardiac arrest and Macones GA. Minor trauma in pregnancy – is the evaluation perimortem caesarean delivery: evidence or expert-based? unwarranted? Am J Obstet Gynecol 2008;198:208e1-5. Resuscitation. 2012 Oct;83(10):1191-200 45. National Highway Traffic Safety Administration. Accessed 61. Lipman S, Daniels K, Cohen SE, Carvalho B. Labor room set- November 19, 2013 at: http://www.nhtsa.gov/ ting compared with the operating room for simulated perimortem cesarean delivery: a randomized controlled trial. Obstet 46 Mattox KL, Goetzl L. Trauma in pregnancy. Crit Care Med. Gynecol. 2011 Nov;118(5):1090-4. 2005; Oct:33(10 Suppl):S385-9 J Matern Fetal Neonatal Med. 2012 Sep;25(9):1612-7. 62. Weber CE. Postmortem cesarean section: Review of the literature and case reports. Am J Obstet Gynecol 1971;110(2):158-165. 47. Weiss HB, Songer TJ, Fabio A. Fetal deaths related to maternal injury. JAMA. 2001 Oct 17;286(15):1863-8. 63. Conde-Agudelo A, Romero R. Amniotic fluid embolism: an evidence-based review. Am J Obstet Gynecol 2009;201:445. 48. Klinich KD, Flannagan CA, Rupp JD, Sochor M, Schneider LW, e1-13. Pearlman MD. Fetal outcome in motor-vehicle crashes: effects of crash characteristics and maternal restraint. Am J Obstet 64. Clark, SL, Hankins GD, Dudley DA, Dildy GA, Porter TF. Gynecol 2008; 198:450e1-e9. Amniotic fluid embolism: Analysis of the national registry. Am J Obstet Gynecol 1995;172:1158-69 49. Weinberg L, Steele RG, Pugh R, Higgins S, Herbert M, Story D. The pregnant trauma patient. Anaethesia and Intensive care 65. Steiner PE, Lushbaugh C. Maternal pulmonary embolism by 2005 33:167-180. amniotic fluid as a cause of obstetric shock and unexpected deaths in obstetrics. JAMA 1941 117:1245-1254, 1340-1345. 50. Schiff MA, Mack CD, Kaufman RP, Holt VL, Grossman DC. The effect of air bags on pregnancy outcomes in Washington State: 66. Moore J, Baldisseri MR. Amniotic fluid embolism. Crit Care 2002-2005. Obstet Gynecol. 2010 Jan;115(1):85-92. Med 2005 33(Suppl.):S279-S285. 51. American College of Obstetricians and Gynecologists. Car 67. Clarke J, Butt M. Maternal collapse. Curr Opin Obstet Gynecol safety for you and your baby. 2011, Available at: http://www. 2005 17:157-160 acog.org/Resources_And_Publications/Patient_Education_ Pamphlets/Files/Car_Safety_for_You_and_Your_Baby Retrieved November 19, 2013 FIGURE LEGEND Figure 1 52. National Highway Traffic Safety Administration. Should Maternal Cardiac Arrest (Figure 117,page 364, AHA: ACLS for Pregnant Women Wear Seat Belts? 2002. Available at: http:// Experienced Providers: hapter 18, 2013) www.nhtsa.dot.gov/people/injury/airbags/Internet_Services_ Group/ISG-Restricted/Buckle-Up%20America/pregnancybro- Figure 2 chure/BUA_PregnancyNHTSAchange.pdf. Retrieved November Howell Full body tilt 19, 2013 Figure 3 53. American Academy of Pediatrics and American College of Howell two handed Manual Left Uterine Displacement technique Obstetricians and Gynecologists. Guidelines for Perinatal Care Figure 4 7th Edition, 2012 Howell one handed Manual Left Uterine Displacemen technique

25 — — Chapter K: Maternal Resuscitation and Trauma APPENDIX I

Injury Severity Score The Injury Severity Score (ISS) is an anatomical scoring system that provides an overall score for patients with multiple injuries. Each injury is assigned an Abbreviated Injury Scale (AIS) score and is allocated to one of six body regions (Head, Face, Chest, Abdomen, Extremities (including Pelvis), External). Only the highest AIS score in each body region is used. The three most severely injured body regions have their score squared and added together to produce the ISS score.

An example of the ISS calculation is shown below: Region Injury Description AIS Square Top Three Head & Neck Cerebral Contusion 3 9 Face No Injury 0 Chest Flail Chest 4 16 Abdomen Minor Contusion of Liver 2 25 Complex Rupture Spleen 5 Extremity Fractured femur 3 External No Injury 0 Injury Severity Score: 50

The ISS score takes values from 0 to 75. If an injury is assigned an AIS of 6 (unsurvivable injury), the ISS score is automatically assigned to 75. The ISS score is virtually the only anatomical scoring system in use and correlates linearly with mortality, morbidity, hospital stay and other measures of severity. It’s weaknesses are that any error in AIS scoring increases the ISS error, many different injury patterns can yield the same ISS score and injuries to different body regions are not weighted. Also, as a full description of patient injuries is not known prior to full investigation & operation, the ISS (along with other anatomical scoring systems) is not useful as a triage tool.

Baker SP et al, “The Injury Severity Score: a method for describing patients with multiple injuries and evaluating emergency care”, J Trauma 14:187-196;1974

26 — — Chapter K: Maternal Resuscitation and Trauma Chapter L slide 1 Safety in Maternity Care Lee T. Dresang, MD Stan Davis, MD Kristi K. Miller, MS, RN Carl Olden, MD Lesley Atwood, MD

Published June 2012

slide 2 ACKNOWLEDGEMENT

slide 3 OBJECTIVES After completing this chapter, participants will be able to: 1. Discuss need for a patient safety focus in maternity care. 2. Describe the team approach to maternity care. 3. Discuss the evidence that team training improves outcomes. 4. Demonstrate teamwork tools that improve safety. 5. Discuss risk management issues in obstetrics and possible solutions (The “five C’s”).

slide 4, 5 INTRODUCTION In 2009, flight 1549 lost both engines. The plane landed on the Hudson River and all 155 aboard survived. Teamwork and communication were cited as key factors in the excellent outcome. Pre-flight training and drills prepared airline workers for their roles when the unanticipated emergency happened. Communication was effective between pilots, crew, passengers, ground control and rescuers. Everyone contributed to the successful outcome.

From its inception ALSO® courses have promoted interdisciplinary teamwork. The courses ideally include participants from different disciplines and different settings. Courses have been taken by many attending physicians (family medicine, obstetrics and emergency medicine), midwives, nurses, residents, students and others. Providers from rural and urban, and academic and community programs can learn from each other’s experiences and perspectives.

ALSO promotes safety by teaching standardized approaches to emergency situations. Knowledge of content, plus practice of manual skills, plus use of mnemonics, reduce the propensity to error. slides 6, 7 Since 2000, the ALSO course has had a chapter devoted to “safety in maternity care.” The lecture, often taught over the lunch-hour featured a role play where a patient was literally and figuratively pulled in different directions by her partner, her nurse, her physician or midwife, and a consultant until Dr. ALSO saves the day. This 2012 chapter revision incorporates new patient safety tools and techniques, and encourages an institutional-focus for ALSO courses. The “Safety in Maternity Care” module is taught at the beginning of the ALSO course so principles can be applied throughout the course.

— Chapter L: Safety in Maternity Care — 1 Why is safety in maternity care important? slide 8 Approximately 342,900 women die from childbirth related causes world-wide.1 Childbirth is the most common reason for admission and cesarean delivery is the most common surgical operation in United States hospitals.2 Improvements in public health and hygiene, advancements in technology, targeted pharmaceutical development, increased training of nurses and physicians, and the development of a regionalized approach to perinatal care in the United States have combined to reduce the overall risk of death and disability related to childbirth in the past century. However, despite these advances, nearly two percent of all obstetrical patients experience an adverse event during childbirth.3 With over four million births in the United States annually,2 this equates to more than 80,000 adverse obstetrical events. “Successful saves” are not included in these numbers. According to the Joint Commission, analysis of adverse obstetrical events suggests that communication failures are a root cause in 72 percent of sentinel events in perinatal units across the United States.4

Even highly trained and dedicated medical professionals make mistakes. Fortunately, most errors slide 9 do not result in harm, and fatal errors are relatively rare.3 Nonetheless, according to the Institute of Medicine’s 2000 report, To Err is Human and the follow up 2001 report Crossing the Quality Chasm, an estimated 44,000 to 98,000 Americans die each year from preventable medical errors.5, 6 Seven percent of hospital patients experience a serious medication error; more Americans die each year from medical errors than from breast cancer, AIDS or car accidents.6 The cost associated with medical errors is estimated at eight to 29 billion dollars annually.6

Team training has been a Joint Commission requirement since 2003. It includes standards which slide 10 require hospitals to “incorporate(s) methods of team training to foster an interdisciplinary, collaborative approach to the delivery of patient care.”7 The 2008 Joint Commission manual requires that ongoing in-services, training or other education incorporate methods of team training when appropriate and that staff participate in education and training that incorporates the skills of team communication, collaboration, and coordination of care.8

While some untoward outcomes cannot be prevented even with exemplary care provided under the best of circumstances, a significant proportion of these cases result from communication and systems problems. One study found that 87 percent of adverse events and potential adverse events were preventable and that poor teamwork, protocol violation and staff unavailability were the most common problems.3 “A team of experts does not make an expert team.”10 slide 11

Most labor and delivery units involve so many providers that a patient care team rarely involves exactly the same people. This high variability in team membership is a key threat to patient safety. Even the most knowledgeable and skilled specialist cannot function to the best of his or her ability without support from a broad array of colleagues.

Evidence that teamwork improves outcomes slides 12, 13 A growing body of evidence documents that improving teamwork improves outcomes. The University of Minnesota and the Fairview Health System has provided an evidence-based springboard for the dissemination of in situ simulation to enhance interdisciplinary communication and teamwork.9, 10 A 2011 study documented a persistent and statistically significant 37 percent decrease in perinatal morbidity at a hospital with teamwork training and drills, compared with no change at a hospital

2 — — Chapter L: Safety in Maternity Care with teamwork training alone, and a control hospital where neither are taught.11 Weighted Adverse Outcome Score (WAOS) and Severity Index (SI) improved 50 percent following implementation of team training on labor and delivery floor at Harvard’s Beth Israel Hospital.12 slides 14, 15 From 2004 to 2006, a patient safety intervention which included outside expert review, protocol standardization, the creation of a patient safety nurse position, implementation of a patient safety committee, and training in team skills and fetal heart monitoring interpretation resulted in a decreased Adverse Outcomes Index (AOI).13 The training included tools now taught by ALSO including the “two-challenge rule” and “CUS” words.13 A randomized controlled trial comparing the Neonatal Resuscitation Program course with and without additional teamwork training demonstrated that those receiving teamwork training in conjunction with the course demonstrated more teamwork behavior at the end of the course.14

Team training may not be enough. “The best team training in the world will not yield the desired outcomes unless the organization is aligned to support it. The next frontier lies in making effective teamwork, as seen in high-performance teams, an essential element in high-reliability organizations.”15

slide 16 MATERNITY CARE TEAM The maternity care team centers around the pregnant woman. A woman’s family members and support network often play an important role. The health care team includes the birth attendant, nurses and consultants. The presence of a doula or professional support person can increase the probability of spontaneous vaginal delivery and reduce the need for pain medicines and instrumental delivery.16

slide 17 Provider strategies for supporting pregnant women include: listening and encouraging mutual trust, anticipating potential problems, discussing options, deriving an acceptable birth plan, allowing a sense of control and assess for entrenched health beliefs, expectations and concerns. Patient- centered interviewing, caring communication skills and shared decision making will promote effective patient-provider communication.17 Involving women in their own care can improve outcomes, satisfaction and compliance.18

slide 18 Provider strategies for working with a woman’s family and support network include: developing relationships with a woman’s partner and family prior to the intrapartum period, assessing cultural norms and expectations, assessing family dynamics, encouraging attendance at childbirth classes and acknowledging existing anger or anxiety. slides 19, 20 The health care team can improve patient safety and satisfaction through good communication, a readily available birth attendant and consultants who are willing to assist in timely fashion. All team member contributions should be respected and encouraged. Characteristics of effective teams include: holding shared mental models, having clear roles and responsibilities, having clear valued and shared vision, optimizing resources, managing and optimizing performance outcomes, having strong team leadership, engaging in a regular discipline of feedback, developing a strong sense of collective trust and confidence and creating mechanisms to cooperate and coordinate.19

— Chapter L: Safety in Maternity Care — 3 Occasionally providers and women do not agree on the plan of care. If this conflict cannot be slide 21 resolved to both parties’ satisfaction, transfer of care may be the preferred option. Documentation is always important, especially in cases of conflict. Providers should document that they explained the implications of the patient’s decisions.

Impediments to team function include personality conflicts, competitive pressures, fixed beliefs slide 22 about abilities or roles, biases regarding management and inadequate resources.

When conflict arises, strategies can help. Separate the people from the problem: be hard on the slide 23 problem, soft on the people. In addition, focus on interests, not positions: focus on concerns and desired outcomes. Invent options for mutual gain; brainstorm to yield “win-win” solutions. Insist on use of objective criteria; this provides basis for further improvement.20

TEAMWORK TOOLS slide 24 Like the medical management and technical skills taught in the ALSO course, teamwork can be taught and learned. Important concepts and tools which can improve teamwork and patient safety include situational awareness, communication out, closed loop communication and shared mental model.

Situational Awareness slides 25-27 In an emergency it is easy to become fixated on a particular task and lose sight of the big picture. A provider may fixate on decelerations on the electronic fetal monitor and lose sight of elevated blood pressures, headache and hyperreflexia prior to an eclamptic seizure. Another provider may focus on preterm contractions and miss an abruption that worsens dangerously with tocolytics. A provider may focus on difficult family dynamics and fail to prepare the team to deal with shoulder dystocia despite a large estimated fetal weight and prolonged second stage.

Team members can help each other remain aware of active issues and potential complications by cross monitoring. Early briefings followed by huddles when new issues arise help assure that all team members are on the same page. Situational monitoring is an important patient safety tool that results in situational awareness.

The acronym STEP can be used to remember important components of situational monitoring: Status of patient Team members Environment Progress towards goal

Communication Out (Call-out, SBAR, Handoff) slides 28, 29 Inadequate communication at change of shift can compromise patient safety. Failing to mention meconium at sign-out just before delivery may result in inadequate newborn resuscitation preparation.

“Call-outs” are used to quickly inform all team members simultaneously when new critical events arise. When dealing with a postpartum hemorrhage, a “Call-out” of high blood pressure alerts the managing provider that methergine (methylergonovine) is contraindicated.

4 — — Chapter L: Safety in Maternity Care slide 30 SBAR stands for Situation, Background, Assessment and Recommendation and is a standard format for communicating critical information.21, 22 Use of SBAR in one institution resulted in an improvement in updating the medicine list on admission from 72 to 88 percent and an improvement in having a corrected medicine list on discharge from 53 to 89 percent.22 The rate of adverse events decreased from 89.9 per 1,000 patient days to 39.96 per 1,000 patient days.22 SBAR can be an effective tool to communicate critical patient care information for physician-nurse communication at shift changes and between providers of different specialties.23 Situation — What is going on with the patient? Background — What is the clinical background or context? Assessment — What do I think the problem is? Recommendation — What would I do to correct it?

Miscommunications in the transfer of care from one provider or care team to another can result in slide 31 life-threatening error. Effective patient handoffs should include interactive communications, limited interactions, a process for verification and an opportunity to review relevant historical data.24

Closed Loop Communication (check back) slide 32 Closed loop communication means that the person receiving a message confirms (repeats back) what they have heard from the person sending the message so that he/she can affirm that it is correct or offer a correction. Closed loop communication allows for a clear shared mental model of the plan of care and the assurance that someone is handling the request. For example, a doctor may order 10 units of oxytocin IM after delivery of the anterior shoulder and a nurse may repeat back that the physician would like 10 units of oxytocin IM after delivery of the anterior shoulder as confirmation that they understood the message. Without closed loop communication, messages may be missed or misinterpreted. In this case, the oxytocin may have not been given or a wrong dose may have been given without closed loop identification.

Shared Mental Model slides 33, 34 Situational awareness, communication out and closed loop communication will allow a team to have a shared mental model. Without a shared mental model, teamwork and patient safety are compromised. The HELPERR mnemonic for shoulder dystocia can create a shared mental model where nurses and physicians work together via McRoberts maneuver, suprapubic pressure and other interventions to avoid fetal injury or death.

In-situ Simulation Drills Drills allow teams to practice managing obstetrical emergencies when patient lives are not at risk. The in-situ drills are done on labor and delivery units rather than in a simulation lab in order to replicate patient care challenges as closely as possible.10 In the drills, teams have a briefing before managing a labor to discuss risks and roles. The team then manages the emergency. Finally, the team debriefs. Following this videotaped exercise, trained facilitators will lead a debriefing session focusing on what went well and why, what did not go well and why, and what can be done to make things go better in the future. Videotaping can be a powerful tool for use in debriefing sessions. Players may see themselves and others quite differently when reviewing videotaped management. Drills allow latent system errors to be identified and corrected before they become active errors leading to patient harm.

— Chapter L: Safety in Maternity Care — 5 BRIEFINGS, HUDDLES AND DEBRIEFINGS slide 35 Before any patient care episode, a briefing session allows team members to review risk factors, des- ignate roles and make sure that everyone has a shared mental model regarding how to proceed. Briefings are a way to “plan ahead.”

Huddles are brief gatherings of team players to discuss patient status and the management plan when issues arise in the course of patient care. Development of high blood pressures during labor, fever and non-reassuring fetal heart tracing are examples of events meriting a huddle. A huddle may take place in person or via teleconference if a key team member is not physically present when the huddle is needed. Huddles are a way to “problem solve” in the moment.

Debriefing allows team players to learn from patient care episodes regardless of the outcome. Team slide 36 members can quickly answer the questions: 1. What went well and why? 2. What could have gone better and why? 3. What would you do different next time?

During debriefings, it can be helpful to discuss three levels of emergency care management: slide 37 1. Medical management 2. Teamwork 3. Systems issues

Discussion may naturally drift to medical management. Team leaders can guide discussion back to teamwork and systems issues. Debriefings can allow the team to do “process improvement.”

FATIGUE slide 38 Fatigue can affect patient safety factors including memory, speed and mood.25 With standardized testing, adults with less than five hours of sleep per night have troubles with short-term memory, retention and concentration.25 Federal Railroad Administration data indicates that approximately 25 percent of train accidents have fatigue as a cause.26 Resident work hour requirements are an attempt to prevent fatigue-related medical errors.

I’M SAFE CHECKLIST: Individuals can make sure that they are fit for work by reviewing an I’M SAFE checklist: Illness Medication Stress Alcohol and Drugs Fatigue Eating and Elimination.

Systems and colleagues can monitor to make sure that work conditions allow for self-care. Employee assistance programs should be high quality and accessible. Work hour limits such as those introduced for medical residents may avoid the fatigue often involved with medical errors.27 Work hours and facilities can facilitate employees eating and eliminating so they will be at their best while working.

6 — — Chapter L: Safety in Maternity Care slide 39 MEDICATION ERRORS The majority of errors are the result of errors with medicines. An example of how medication errors can be fatal occurred in 2006 when a healthy sixteen year old was admitted in active labor to a hospital in Madison, WI.28 She was group B strep positive and wanted an epidural. The anesthesiologist left the epidural bag on the counter and stepped out of the room. The nurse walked in the room and hung the epidural bag, thinking it was penicillin. Despite resuscitative efforts, the young woman died. Her baby lived after a peri-mortem cesarean.

Electronic medical records are helpful in reducing errors due to poor legibility and can pick up drug allergy and drug interaction issues. Prescribing errors can be reduced by avoiding non-standard abbreviations and using the “always lead, never follow” rule of putting a zero before numbers less than one and not putting a zero after a decimal point.29 Using closed loop communication can be lifesaving.

FIX SYSTEMS RATHER THAN BLAME INDIVIDUALS Reducing medical error to improve patient safety is a high priority in the United States and other countries. Traditionally, medical culture expects perfection. The typical tactic to “fix” errors is to ascribe individual blame.

While the analysis of a particular error may often lead to a single human action or omission, the error is often caused by numerous other factors. Blaming the individual leaves those other factors in place and allows the error to repeat itself. For example, firing an employee who makes an error at the end of a double shift does not fix the work hour structure that will likely lead to fatigue and error again. Examples of ways to effect change at a systems level, checklists and protocols have been documented to improve outcomes through standardization of practice.30

In the early days of aviation, accidents were often blamed on “pilot error” with little further analysis. Blaming the faulty, and usually dead, pilot did little to prevent further crashes. The aviation industry made little progress in safety and reliability until they developed a broader notion of safety and looked at the multiplicity of factors underlying aircraft accidents and pilot errors. Aviation safety improved through a “collective sense of urgency for maintaining safety and a mutual understanding that all team members will state their observations, opinions, and recommendations, and actively solicit and consider input from other team members.”31

Empower all team members An important tenet of aviation safety is to empower each member of the flying team to identify potential errors and correct them.32 The aviation industry has found that this helps overcome the effects of their traditionally hierarchical organization, which otherwise tends to discourage error reporting by subordinates. The medical profession has a similarly hierarchical organization and must overcome this tendency to silence. Tools such as the “two challenge rule”33 and CUS establish mechanisms for all to speak up and contribute when issues arise. The “two challenge rule” implies that anyone can stop current actions until their concern is addressed after their concern is voiced twice. With the “CUS” tool, everyone in a care unit is trained that when the buzz words “I’m Concerned; I’m Uncomfortable; This is a Safety issue” are used, everyone needs to listen.

— Chapter L: Safety in Maternity Care — 7 Patient aafety also reduces malpractice risk An additional anticipated benefit of a reduction in adverse obstetric outcomes is a decrease in malpractice loss experience for physicians and hospitals providing maternity care. Throughout the United States, pregnancy and birth-related claims top the list in malpractice loss expenses; it is not surprising that these losses have driven many hospitals and physicians from the practice of maternity care. It is estimated that approximately $80 billion per year is spent on defensive medicine.34 Preventing patient errors is an important part of a multifaceted approach to resolving what many perceive as a current malpractice crisis.35 President Barack Obama and Hillary Clinton co-authored a New England Journal of Medicine article stating that patient safety should be the centerpiece of medical liability reform.36

The cost of malpractice insurance can affect the ability to provide maternity care and the satisfaction of those who pay high premiums. Multivariate regression analysis of a survey of Michigan OB/GYNs with 365 respondents showed that compared to coverage through an employer, paying more than $50,000/year for liability insurance was associated with lower career satisfaction (odds ratio (OR) 0.35; 95% confidence interval (CI) 0.13– 0.93).37

Medical liability concerns need not detract from the joy and satisfaction of caring for pregnant women. Knowledge of the principles of risk management and common obstetrical allegations provides clinicians greater understanding, a greater sense of control and improves patient safety.

Pregnancy is unique from a liability standpoint in several ways: 1) two patients are involved: the woman and her fetus, 2) the woman is usually healthy when she presents for care, and 3) she and her family often have expectations of the perfect baby and the perfect birth experience.

An unhappy patient is the usual trigger for a lawsuit.38 This may reflect the patient’s or her family’s feelings of disappointment at the outcome, the kind or cost of care she received, or the cost of caring for a child with a handicapping condition.

Malpractice litigation takes a tremendous toll on all involved. Lawsuits usually take many years to resolve. There are uncounted costs, and even the loss of maternity care providers. Defensive medical practices, time lost in litigation activities, increased wariness toward patients and emotional tur- moil are costly results of litigation. Loss of access to maternity care is also exacerbated, especially in rural areas.39

Malpractice litigation is a common event. Eighty-nine percent of respondents to a 2006 survey of ACOG fellows indicated that they had been sued with an average of 2.6 claims per obstetrician.40 Costs of litigation and awards continue to climb in the United States and Canada. The likelihood of a suit appears to be directly related to the volume of deliveries a professional performs rather than to quality or specialty. Family physicians are not exempt. It is also a myth that poor people sue more frequently.41

8 — — Chapter L: Safety in Maternity Care Diagnostic error is now the second leading cause of all professional liability claims in the United States and affects all medical specialties. “Failure to diagnose” claims costs have increased by 285 percent in the late 1990’s.42 Eight common allegations are made in maternity claims: slide 40 1. Negligent antepartum care (e.g. failure to diagnose gestational diabetes or multiple gestation) 2. Inadequate or negligent genetic counseling (e.g. failure to identify an inheritable disease such as Tay-Sachs disease, or failure to offer genetic counseling and testing to the woman who reaches age 35 by birth) 3. Negligent management of pregnancy-related complications (e.g. mismanagement of pre-eclampsia) 4. Negligent monitoring of the fetus during labor (e.g. failing to follow established protocols for auscultative or electronic monitoring of fetus and failure to document fetal well-being) 5. Improper use of oxytocics, induction and augmentation of labor (e.g. using a high dose oxytocin regimen for induction of a multipara, or elective induction of labor causing iatrogenic prematurity). 6. Improper diagnosis and management of abnormal labor (e.g. failure to have a management plan for a patient with abnormal progression of labor, or failure to diagnose uterine rupture) 7. Negligent management of delivery complications including malpresentation, forceps, and shoulder dystocia (e.g. failure to use established safety guidelines for vacuum, excessive attempts at vacuum extraction) 8. Improper timing of cesarean delivery (e.g. failure to choose to do an indicated abdominal delivery or inability to initiate an operative birth within 20 to 30 minutes of the decision to operate)

Risk management is a strategy that attempts to prevent or minimize patient injuries, decreases the chance of successful malpractice litigation when an injury does occur and attempts to reduce the size of the award in a successful claim. Risk management strategies in hospitals have tried to use early case reporting to help decrease claims. Malpractice claims are not sensitively or specifically identified by these strategies. Newer strategies focus on root cause analysis to prevent future adverse outcomes. The Veterans Administration system has used a novel approach of intense case finding, coupled with apology and negotiation, with injured patients.43 They have successfully decreased overall claims costs while compensating injured patients even before initiation of lawsuits.

Malpractice insurance rates Many professional liability insurance companies offer discounts on medical malpractice premiums to maternity care provider clients who successfully complete the ALSO Provider Course. Northwest Physicians Mutual recommends successful completion of the course as a prerequisite to eligibility for professional liability coverage.44 slide 41 The Five Cs of risk management Since the inception of the Safety in Maternity Care chapter, ALSO has taught the five Cs of risk management Compassion, Communication, Competence, Charting and Confession.45

Compassion — Every lawsuit begins with a dissatisfied patient. Often this dissatisfaction starts before the event leading to the suit. Patients find it more difficult to sue someone they like and who they believe cares about them. Allow the woman to choose from a variety of options of care when possible. Allow her to share her concerns. Open ended questions which can improve empathy include “Tell me more,” “How did you feel,” “Anything else?” and “What concerns do you have?”46

— Chapter L: Safety in Maternity Care — 9 Communication — Spending more time with the patient will result in fewer lawsuits. Patients do not want to feel rushed. Patients who receive adequate explanations about their conditions and test results are more satisfied. Patients do not want to feel that their maternity care provider ignored their concerns.

Communication implies being available to the patient and maternity care team. A woman in labor virtually takes precedence over any other patient.

Informed consent is an important tool to use to help women and families understand and share some of the uncertainty and risk inherent in pregnancy. Informed consent is inherently imperfect: it “depends on there being a shared understanding of the language used to describe the risks and benefits of the appropriate available options.”47 Closed-loop communication and the combination of verbal description, numerical data and graphical representation can facilitate common understanding of risks and benefits.

To inform a patient, information must be given in their primary language. Head nodding is often misinterpreted as understanding when talking with women who speak a different language. It is not appropriate to rely on family members to translate; content may be private or technical and family members should be allowed to focus on their own priorities.

Strategies for facilitating communication include: • Speaking slowly and using plain, nonmedical language • Limiting the amount of information provided and repeating the information • Using return demonstration techniques (asking the patient to repeat any instructions given) to confirm that the patient understands what has been explained • Encouraging patients to ask questions • Providing written materials to reinforce oral explanations48

Communication between other colleagues involved in the woman’s care is also crucial. In the evaluation of infant death in the United Kingdom, one of the more frequently identified aspects of sub-optimal care was a lapse in communication between parts of the system. This led to delays in diagnosis and early intervention of adverse events.

Competence — The clinician must know his or her ability in any given situation. Honesty and making sure that interventions are solidly indicated are important features of competence. The provider must possess skill, training, experience and comfort to provide appropriate care. Consultation or referral should be obtained and appropriately documented when these criteria are not met.

Charting — Many suits are filed and lost because of inadequate documentation in the medical record. The medical record serves as the principal witness when an action is filed. A suit is usually litigated years later, and memories fade. Records should be dated, timed, complete, contemporaneous, accurate, and objective. Recording errors should be addressed, corrected and explained; they should never be ignored or covered up. Even an uncomplicated vaginal delivery should have a complete and legible record. Dictated reports should be read, corrected and signed. Avoid inflammatory, incorrect, and vague terms such as “fetal distress” and “asphyxia.

10 — — Chapter L: Safety in Maternity Care In one study, with 54 percent of malpractice cases involving shoulder dystocia, the issue driving payment was lack of clear documentation of events surrounding the management of the dystocia.49 Only 25 percent had a deviation from standard of care.49

Confession — Discussing mistakes with the patient has been actively discouraged in the past. However, many studies confirm that one of the more common reasons for filing a suit is because the patient suspected a cover up.50 A survey of patients at an academic internal medicine clinic found that almost all patients wanted their physician to disclose even minor errors.51

These five C components of risk management serve as a reminder of strategies to decrease malpractice risk. More importantly, they serve as excellent strategies for the maternity care provider to ensure satisfying, safe care for pregnant women and their families.

An ACOG Committee Opinion makes seven patient safety recommendations: 1) develop a com- mitment to encourage a culture of patient safety, 2) implement recommended safe medicine practices,52, 53 3) reduce the likelihood of surgical errors, 4) improve communication with health care providers, 5) improve communication with patients, 6) establish a partnership with patients to improve safety, and 7) make safety a priority in every aspect of practice.29 slide 42 SUMMARY Women and their babies die and suffer permanent injury because of preventable errors. Routine use of briefings, huddles and debriefings will help avoid communication errors, which account for over 70 percent of medical errors. Teamwork tools include: situational awareness, communication out, closed-loop communication and shared mental model. Tools such as the two-challenge rule and CUS words empower everyone involved in patient care to speak up and influence care when they perceive errors in the making. ALSO® mnemonics help team members to “sing from the same songbook” when emergencies arise. Following the five Cs will reduce the risk of malpractice litigation through improved patient care. Learners are encouraged and challenged to incorporate team thinking during ALSO training and subsequent practice.

— Chapter L: Safety in Maternity Care — 11 REFERENCES

1. Hogan M, Foreman K, Naghavi M, Ahn S, Wang 14. Thomas E, Taggart B, Crandell S, Lasky R, Williams A, M, Makela S, et al. Maternal mortality for 181 coun- Love L, et al. Teaching teamwork during the Neonatal tries, 1980-2008: a systematic analysis of progress Resuscitation Program: a randomized trial. J Perinatol towards Millennium Development Goal 5. Lancet 2007;27:409-414. 2010;375:1609-1623. 15. Salas E, Gregory M, King H. Team training can 2. Russo C, Wier L, Steiner C. Hospitalizations Related to enhance patient safety--the data, the challenge ahead. Childbirth, 2006. HCUP Statistical Brief #71. April 2009. Jt Comm J Qual Patient Saf 2011;37:339-340. U.S. Agency for Healthcare Research and Quality, 16. Hodnett E, Gates S, Hofmeyr G, Sakala C, Weston Rockville, MD. http://www.hcup-us.ahrq.gov/reports/ J. Continuous support for women during childbirth. statbriefs/sb71.pdf Site last visited February 18,2012. Cochrane Database Syst Rev 2011. 3. Forster A, Fung I, Caughey S, Oppenheimer L, Beach 17. American College of Obstetricians and Gynecologists. C, Shojania K, et al. Adverse events detected by Effective Patient-Physician Communication. Committee clinical surveillance on an obstetric service. Obstet Opinion No. 492. Obstet Gynecol 2011;117:1254-1257. Gynecol 2006;108:1073-1083. 18. American College of Obstetricians and Gynecologists. 4. The Joint Commission (2007). Perinatal deaths and Partnering with patients to improve safety. Committee injuries. Sentinel Event Statistics-March 31, 2007: Opinion No. 490. Obstet Gynecol 2011;117:1247-1249. Root Cause Statistics. http://www.jointcommission. org/SentinelEvents/Statistics/. Site last visited 19. Department of Defense. TeamSTEPPS[TM] Instructor February 18, 2012. Guide. [TeamSTEPPS[TM]: Team Strategies & Tools to Enhance Performance and Patient Safety. Rockville (MD): 5. Committee on Quality of Health Care in America, Agency for Healthcare Research and Quality; 2006. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century: National 20. Fisher R, Ury W, Patton B. Getting to Yes: Negotiating Academies Press; 2001. Agreement Without Giving In: Penguin; 2011. 6. Committee on Quality of Health Care In Medicine; 21. McFerran S, Nunes J, Pucci D, Zuniga A. Perinatal Institute of Medicine. To Err is Human: Building a Patient Safety Project: a multicenter approach to Safer Health System: National Academy Press; 2000. improve performance reliability at Kaiser Permanente. J Perinat Neonatal Nurs 2005;19:37-45. 7. 2003 Joint Commission National Patient Safety Goals Manual. http://www.jcrinc.com/. Site last visited 22. Haig K, Sutton S, Whittington J. SBAR: a shared March 6, 2011. mental model for improving communication between clinicians. Jt Comm J Qual Patient Saf. 2006;32:167-175. 8. 2008 Joint Commission National Patient Safety Goals Manual. http://www.jcrinc.com/. Site last 23. Leonard M, Graham S, Bonacum D. The human fac- visited March 6, 2011. tor: the critical importance of effective teamwork and communication in providing safe care. Qual Saf Health 9. Davis SR, W, Gurses A, Miller K, Hansen H. Failure Care 2004;13:i85-i90. Modes and Effects Analysis Based on In Situ Simulations: A Methodology to Improve Understanding 24. American College of Obstetricians and Gynecologists. of Risks and Failures. http://www.ahrq.gov/down- Communication strategies for patient handoffs. Committee loads/pub/advances2/vol3/Advances-Davis_60.pdf. Opinion No. 517 Obstet Gynecol 2012;119:408-411. Website last visited March 6, 2011. 25. American College of Obstetricians and Gynecologists. 10. Miller K, Riley W, Davis S, Hansen H. In situ simula- Fatigue and patient safety. Committee Opinion No. 519. tion: a method of experiential learning to promote Obstet Gynecol 2012;119:683-685. safety and team behavior. J Perinat Neonatal Nurs 26. Federal Railroad Administration. The railroad fatigue 2008;22:105-113. risk management program at the federal railroad 11. Riley W, Davis S, Miller K, Hansen H, Sainfort F, Sweet administration: past, present and future.Washington, R. Didactic and simulation nontechnical skills team DC: FRA; 2006. http://www.fra.dot.gov/downloads/ training to improve perinatal patient outcomes in a safety/fatiguewhitepaper112706.pdf. Site last visited community hospital. Jt Comm J Qual Patient Saf January 11, 2010. 2011;37:357-364. 27. Spritz N. Oversight of physicians’ conduct by state 12. Mann S, Marcus R, Sachs B. Lessons from the licensing agencies. Lessons from New York’s Libby Cockpit: How Team Training Can Reduce Errors on Zion case. Ann Intern Med 1991;115:219-222. L&D. Contemp Ob Gyn 2006:34-45. 28. Smetzer J, Baker C, Byrne F, Cohen M. Shaping sys- 13. Pettker C, Thung S, Norwitz E, Buhimschi C, Raab tems for better behavioral choices: lessons learned C, Copel J, et al. Impact of a comprehensive patient from a fatal medication error. Jt Comm J Qual Patient safety strategy on obstetric adverse events. Am J Saf 2010;36:152-163. Obstet Gynecol 2009;200:e1-8.

12 — — Chapter L: Safety in Maternity Care 29. American College of Obstetricians and Gynecologists. 46. American College of Obstetricians and Gynecologists. ACOG committee opinion number 447: Patient Empathy in women’s health care. Committee Opinion safety in obstetrics and gynecology. Obstet Gynecol No. 480. Obstet Gynecol 2011;117:756-761. 2009;114:1424-1427. 47. Cabeeza P, Ramisetty P, Thompson P, Khan K. Risk 30. American College of Obstetricians and Gynecologists. communication: illusion or reality? J Obstet Gynaecol Standardization of practice to improve outcomes. 2005;25:635-637.

Committee Opinion no. 526. Obstet Gynecol 48. Weiss B. Health literacy and patient safety: help 2012;119:1081-1082. patients understand. http://www.ama-assn.org/ama1/ 31. Lyndon A. Communication and teamwork in patient pub/upload/mm/367/healthlitclinicians.pdf. Site care: how much can we learn from aviation? J Obstet last visited May 9, 2012. 2nd ed. Chicago: American Gynecol Neonatal Nurs 2006;35:538-546. Medical Association Foundation; 2007. 32. Nance J. Keynote speech. National Forum on Quality 49. Clark S, Belfort M, Dildy G, Meyers J. Reducing Improvement in Healthcare. New Orleans; 1999. obstetric litigation through alterations in practice 33. Macready N. Two-challenge rule averts errors, patterns. Obstet Gynecol 2008;112:1279-1283. improves safety. OR Manager 1999;15:12. 50. American College of Obstetricians and Gynecologists. 34. Pearlman M. Patient safety in obstetrics and gyne- Disclosure and discussion of adverse advents. Committee Opinion No. 520. cology: an agenda for the future. Obstet Gynecol Obstet Gynecol 2006;108:1266-1271. 2012;119:686-689. 35. Weinstein L. A multifacited approach to improve 51. Witman A, Park D, Hardin S. How do patients want patient safety, prevent medical errors and resolve physicians to handle mistakes? A survey of internal medicine patients in an academic setting. the professional liability crisis. Am J Obstet Gynecol Arch Intern 2006;194:1160-1165. Med 1996;156:2565-2569. 36. Clinton H, Obama B. Making patient safety the 52. ACOG Committee Opinion. Safe use of medication. Number 331. 2006;107:969-972. centerpiece of medical liability reform. N Engl J Med Obstet Gynecol 2006;354:2205-2208. 53. ACOG Committee Opinion No. 400: Technologic 37. Xu X, Siefert K, Jacobson P, Lori J, Ransom S. advances to reduce medication-related errors. The impact of malpractice burden on Michigan Committee on Patient Safety and Quality Improvement. obstetrician-gynecologists’ career satisfaction. Obstet Gynecol 2008;111:795-798. Womens Health Issues 2008;18:229-237. 38. Huycke L, Huycke M. Characteristics of potential plaintiffs in malpractice litigation. Ann Intern Med 1994;120:792-798. 39. Burns L, Connolly T, DeGraaff R. Impact of physicians’ perceptions of malpractice and adaptive changes on intention to cease obstetrical practice. J Rural Health 1999;15:134-146. 40. Chervenak J. Overview of professional liability. Clin Perinatol 2007;34:227-232. 41. Baldwin L, Greer T, Wu R, Hart G, Lloyd M, Rosenblatt R. Differences in the obstetric malpractice claims filed by Medicaid and non-Medicaid patients. J Am Board Fam Pract 1992;5:623-627. 42. Bartlett E, KI H, Bobetic K, Douglass M, Johnson L, Machnowski G, et al. The early diagnosis project: a collaborative approach to risk management. J Healthc Risk Manag 1999;19:21-27. 43. Kraman S, Hamm G. Risk management: extreme honesty may be the best policy. Ann Intern Med 1999;131:963-967. 44. Northwest Physicians Mutual. OB initiatives. Recommendation #4. 45. Roberts R. Seven reasons family doctors get sued and how to reduce your risk. Fam Pract Manag 2003;10:29-34.

— Chapter L: Safety in Maternity Care — 13 Chapter N Third and Fourth Degree Perineal Lacerations slide 1 Timothy Canavan, M.D., MSc Published June 2012

slide 2 OBJECTIVES After completing this chapter, participants will be able to: 1. Review the classification of perineal lacerations 2. Discuss etiology of third and fourth degree lacerations 3. Review techniques and evidence concerning third and fourth degree repair 4. Discuss complications of third and fourth degree lacerations

slide 3 INTRODUCTION Third and fourth degree perineal lacerations are a common complication of vaginal delivery, especially in the presence of a midline episiotomy or an operative delivery. Correct evaluation and repair is necessary to prevent complications. The degree of laceration is graded and determines the method of repair. slides 4, 5 EPIDEMIOLOGY Third and fourth degree lacerations can follow any type of vaginal delivery. Many studies have found that episiotomy is the factor with the strongest association with a third or fourth degree laceration.1 Restrictive episiotomy policies appear to have a number of benefits compared to routine episiotomy policies. There is less posterior perineal trauma, suturing, and pain, but there is an increased risk of anterior perineal trauma with restrictive episiotomy.2 Anterior trauma has not been found to have an effect on postpartum urinary continence at 12 weeks post partum, but the long term effects continue to be uncertain.3

Certain other factors have been found to predispose to these lacerations (Table 1). A Cochrane Review of 10 trials4 found that, compared to forceps, the vacuum extractor was associated with less maternal trauma and therefore, less likely to be associated with a third or fourth degree laceration. Factors not associated with these lacerations include: body mass index (BMI), gestational age, marital status, pre- pregnant weight, weight gain in pregnancy, height, education, time of birth or physical fitness. 3, 7

Table 1. Factors Associated with Third and Fourth Degree Lacerations1-9

Anesthesia (local and epidural) Nulliparity Asian or Pacific Islander ethnicity Occiput transverse or occiput posterior positions Delivery with stirrups (delivery table, lithotomy) Operative delivery (forceps > vacuum) Routine episiotomy (midline > mediolateral) Patient age (< 21 years) Increasing birth weight Use of oxytocin Increased second stage of labor

— Chapter N: Third and fourth Degree Perineal Lacerations — 1 ANATOMY The perineum is composed of multiple layers, including an epithelium and several fascial and muscular layers which are disrupted during the occurrence of a third or fourth degree laceration. Detailed understanding of the anatomy of the perineum is essential for proper repair.

From superficial to deep, the laceration involves the squamous epithelium of the perineum and the vaginal mucosa. Directly beneath this layer at the posterior margin of the introitus, is the perineal body. The perineal body is the central tendon of the perineum where the bulbocavernosus (also called the bulbospongiosus), superficial transverse perineal and external anal sphincter muscles join. The perineal body is actually triangular in shape when visualized in the sagittal plane. Its base is at the perineum and the apex at the top of the vagina. Superficial and deep to these muscles are layers of fascial tissue. Beneath the deep layer of fascia lies the deep transverse perineal muscle and the levator ani muscles, respectively, as you dissect superiorly. Posterior to and originating inferiorly from the levator ani muscle, is the internal anal sphincter. Directly beneath the internal anal slide 6 sphincter is the rectal mucosa.

The internal anal sphincter may not be a familiar anatomic structure for many physicians and midwives as it was not well described in older obstetrical texts. It is smooth muscle and provides most of the resting anal sphincter tone and continence. There is evidence that a laceration involving both the external anal sphincter (EAS) and internal anal sphincter (IAS) has a higher likelihood of postpartum fecal incontinence. The presence of an IAS defect on endoanal ultrasound is associated with anal incontinence in some but not all studies.10, 11

CLASSIFICATION slide 7 A classification system establishes a frame of reference for evaluation, research and discussion of the degree of damage as well as the proper means for repair. In the US a four level classification system is used as compared to a three level system in Europe (the European third being equivalent to the US fourth). See table 2.

Table 2. Classification1 Degree of laceration Description

First degree Superficial laceration of the vaginal mucosa or perineal body.

Second degree Laceration of the vaginal mucosa and/or perineal skin and deeper subcutaneous tissues.

Third degree Incomplete Second degree laceration with laceration of the capsule and part (but not all) of the anal sphincter muscle.

Complete As above with complete laceration of the anal sphincter muscle.

Fourth degree Laceration of the rectal mucosa.

2 — — Chapter N: Third and Fourth Degree Perineal Lacerations slide 8 PREVENTION Avoiding an operative delivery or episiotomy has been shown to be the best way to prevent a third or fourth degree laceration. If one must perform an operative delivery, then use of the vacuum extractor, rather than the forceps for assisted delivery, appears to reduce maternal morbidity.4 There have been several studies evaluating other preventive strategies with mixed results. A systemic review found that perineal massage started weeks before delivery increased the chance of an intact perineum with a first vaginal delivery but not in women with a previous vaginal birth.5 A randomized controlled trial (RCT) found that although a perineal warm pack did not reduce the likelihood of nulliparous women requiring suturing, it did significantly reduce third and fourth degree lacerations and pain during birth.6 Another RCT12 did not find any difference in the risk of genital trauma with the use of warm compresses, massage with lubricant or no touching of the perineum. The literature is mixed on the best birth position, but the lateral position has the strongest evidence for an increased likelihood of an intact perineum after delivery especially in the presence of regional anesthesia.13, 14 One RCT15 found that perineal support at delivery did not decrease the frequency or degree of perineal lacerations compared to a “hands-off” approach while a second RCT found that a “hands on” (perineal support with pressure on the fetal head) approach decreased perineal pain on post partum day 10 with an increased risk of episiotomy.16 There was a decrease in the number of 3rd and 4th degree laceration with the “hands” on approach which was not statistically significant. See Table 3.

Table 3. Preventive Strategies 4-6, 12-16 Allow time for adequate perineal thinning Avoid an operative delivery (forceps > vacuum) Avoid episiotomy Perineal massage during the weeks before delivery in nulliparas Lateral birth position Perineal warm packs during the second stage

SURGICAL REPAIR Evaluation slides 9, 10 Prior to beginning the repair, the clinician should obtain the necessary equipment and assistance for proper exposure. See Table 4 & 5. It is essential that the full extent of the laceration be known with specific attention to the presence of extension into the internal anal sphincter and rectal mucosa and how superior the laceration extends. Even experienced physicians and midwives commonly miss the presence of a 3rd degree laceration.16 A rectal examination is recommended for deeper second degree lacerations. It is important to check for the so-called “button hole” defect in the rectal mucosa. This describes the fourth degree laceration in which the mid portion of the rectal mucosa is spared. The clinician misses the upper injury, repairing only the more inferior laceration. As a result, a high rate of fistula and infectious morbidity occurs. The clinician should perform a detailed rectal exam before beginning the repair. The examiner should gently elevate the anterior rectal wall into the vagina. Either the examiner or an assistant sponges and retracts so that optimal visualization is made of the defect and the surrounding tissues. The length of the laceration, the presence of buttonholes, the condition of the surrounding anatomical structures, and any bleeding points can be easily identified. The rectal glove may be changed before continuing with the repair and copious irrigation is encouraged to minimize the risk of infection from colonic bacteria.

— Chapter N: Third and fourth Degree Perineal Lacerations — 3 Table 4. Suture Materials18, 19 Suture Brand Name(s) Composition Qualities Duration Polyglycolic Vicryl Braided synthetic Better and longer Predictable absorption acid Vicryl Rapide of a glycolic acid tensile strength than by hydrolysis. Totally Dexon homopolyjmer chromic. Mild tissue absorbed at 60 to response. Decreases 90 days. short term pain.

Polyglycolic Maxon Monofilament Excellent tensile Absorbed completely by acid and composed 1:3 strength. Smooth and hydrolysis at 180 days. trimethalene of the noted resists kinking. polymers

Polydioxanone PDS Duracryl Monofilament long Excellent tensile Absorbed completely by sulfate lasting, delayed strength. Smooth and hydrolysis at 180 days absorbable pliable.

Chromic gut Chromic Twisted lengths Good tensile strength. Absorption by of proteinaceous Strong inflammatory phagocytosis which sheep or beef response. is unpredicctable. intestinal lining Maintains tensile strength from seven to 10 days. Faster absorption in infected tissue.

Table 5. Equipment List for Third and Fourth Degree Laceration Repair

Allis clamps (two) Gelpi retractor Irrigation Local anesthetic Needle holder Sharp tooth tissue forceps Sponges Needle/Sutures* – 2-0 Polyglycolic acid or PDS on a large taper needle for anal sphincter and vagina/perineum repair – 4-0 Polyglycolic acid on a small taper needle for rectal mucosa repair Syringe & needle (Iowa trumpet) Vaginal pack

*sutures may vary depending on clinician

The choice of suture material has historically been at the discretion of the clinician; however, evidence suggests that absorbable, synthetic suture is the best choice. A Cochrane Review18 comparing absorbable synthetic with plain or chromic catgut suture for perineal repair included 18 trials of good quality and found that synthetic suture was associated with less pain in the first three days after delivery, less need for analgesia, and less suture dehiscence. There was no significant difference in long term pain or the amount of dyspareunia women experienced. Suture removal was significantly more common with synthetic suture. There was no difference between standard synthetic and rapidly absorbing synthetic sutures; except for an increased risk of suture removal. One trial comparing monofilament with standard polyglycolic sutures found no difference for most outcomes.20

4 — — Chapter N: Third and Fourth Degree Perineal Lacerations slide 11 ANALGESIA Pudendal block with or without local anesthesia should provide adequate analgesia for the majority of repairs. This can be placed prior to the performance of an episiotomy or after the birth prior to the repair. The choice of anesthetic can be at the discretion of the provider but most use lidocaine, chloroprocaine or bupivacaine with epinephrine. Lidocaine transfers quickly to the fetus and must be used sparingly.21 Chloroprocaine is rapidly metabolized in the mother and fetus and has poor placental transfer. Bupivacaine is more protein bound and has a lower transfer rate to the fetus but has potential for maternal cardiac toxicity.

A pudendal anesthesia is an ideal regional block for the repair of a third or fourth degree laceration when an epidural is not in place. It provides excellent anesthesia of the central perineum and lower slide 12 vagina by blocking the dorsal nerve of the clitoris, labial nerves and inferior rectal nerve.21 Patients who are unable to tolerate the repair with an adequate pudendal block, may be best managed with inhalation or intravenous analgesia. Those patients with an epidural in place can have it “topped off” to provide the necessary analgesia. Postpartum spinal anesthesia is another option as a cooperative and comfortable patient is important for good exposure and adequate repair.

The pudendal regional block can be given using a transvaginal approach with the assistance of an Iowa trumpet and a 20-gauge spinal needle.21 Five to 10 milliliters of a local anesthetic are injected slide 13 bilaterally just below the ischial spines.21 The pudendal nerve is in close proximity to the pudendal artery and vein. This increases the likelihood for intravessel injection, vessel laceration and rapid circulatory absorption of the anesthetic. The operator should aspirate prior to injection to ascertain that the needle is not within a vessel.

Adequate analgesia can also be obtained using local infiltration with an anesthetic. Infusing a local anesthetic into the vaginal mucosa, perineum and rectal sphincter may provide enough analgesia to complete the repair. Care should be taken to assure that the rectal sphincter is adequately anesthe- tized before beginning the repair.

LACERATION REPAIR Once adequate analgesia has been obtained, the repair can be started. The following describes a fourth degree laceration repair but a third degree laceration repair begins after closure of the rectal mucosa.

Adequate exposure and visualization of the laceration is the most important step prior to beginning the repair. Several techniques can be used to provide this. Many clinicians used one or two assistants to provide retraction and a vaginal pack (a long gauze pad with a blue string for removal) placed into the upper vagina to stop the flow of blood into the surgical field. Some clinicians use sponges when a vaginal pack is unavailable. When the clinician does not have the luxury of assistants, a retractor can be used called a gelpi. The gelpi is an adjustable, self-retaining retractor that can be used to spread the vaginal walls.

After good exposure is obtained, a 3-0 or 4-0 absorbable synthetic suture on a small tapered needle slide 14 is used to reapproximate the rectal mucosa using an interrupted imbricating pattern. An anchor stitch should be placed at least 0.5 cm above the apex of the incision and running unlocked sutures should be placed approximately 0.5 cm apart. This suture should be carried beyond the anal verge onto the perineum by one stitch. Some clinicians use Interrupted sutures.1 Most clinicians use an

— Chapter N: Third and fourth Degree Perineal Lacerations — 5 imbricating method to avoid placement of sutures into the rectal lumen and we do not recommend revising a repair if a suture is palpable in the rectal lumen after repair is completed. There are no data to support one method over another.1

Prior to closure of the external anal sphincter, the internal anal sphincter should be identified and re-approximated. It is usually seen as a pale to white, longitudinal, fibrous layer between the rectal slides 15, 16 mucosa and the external anal sphincter. It can vary in thickness and can be difficult to distinguish from the rectal mucosa. Once identified, it should be re-approximated with a running unlocked or interrupted 2-0 absorbable synthetic suture.

The ends of the external anal sphincter must be clearly identified. They usually retract into the capsule laterally and will need to be grasped and brought anteriorly and medially. This can be done using Allis clamps. The Allis clamp is used to grasp the muscle with its associated posterior and anterior capsules. Historically, there have been two techniques recommended to reapproximate slides 17-19 the sphincter: the end-to-end repair and the overlap repair. A Cochrane review22 of 3 randomized controlled trials found that the overlap technique was associated with lower risks for fecal urgency and anal incontinence symptoms. However, there was considerable heterogeneity among the studies and the experience of the surgeon was not addressed in these trials. The review was unable to recommend one technique over the other. A randomized trial11 published after the Cochrane review found that an end-to-end repair was associated with lower rates of anal incontinence compared to the overlap technique. The primary outcome was flatal incontinence at 6 months. These findings would suggest that the end to end repair may have some benefit over the overlap technique.

The sphincter should be reapproximated using several carefully placed 2-0 polyglycolic acid interrupted sutures on a large tapered needle (Figure 6b). The first suture should be placed at the bottom, which is the most posterior portion of the sphincter. It is important to grasp at least one centimeter of the fascial capsule since this is the most supportive tissue. This should be followed by interrupted sutures at the front, back and top. Other sutures can be placed as clinically necessary for complete reapproximation of the sphincter. Many clinicians recommend avoiding figure-of-eight sutures because of the theoretical risk of tissue strangulation with resultant devascularization and poor healing.1

The remaining laceration should then be examined for depth. To decrease the dead space, and prevent future rectocele development, the rectovaginal fascia (also known as the perineal membrane, Denoviller’s fascia or the rectovaginal septum) should be repaired with interrupted or running 2-0 or 3-0 absorbable synthetic suture. This layer help with posterior pelvic floor support and extends to the levator ani muscle, sacrum and the perineal body. Care should be taken to prevent entry into the rectal lumen. Some clinicians use a running 00 absorbable synthetic suture closure. There are no data to support one method over the other. In a third of fourth degree laceration much of the recto vaginal fascia has been exposed and can be repaired as another layer after the internal sphincter. In more superficial vaginal lacerations the rectovaginal fascia may be repaired as part of the running suture that reapproximates the vaginal mucosa and the inferior margin of the rectovaginal fascia may be reattached to its insertion on the perineal body muscles.

6 — — Chapter N: Third and Fourth Degree Perineal Lacerations The remainder of the closure can be performed in the usual technique of a midline episiotomy. The vaginal mucosa can be closed with a variety of techniques and sutures, but an absorbable syn- slide 20 thetic suture material is recommended. The apex of the incision should be identified and the suture placed at least 1 cm above the apex. This provides improved hemostasis and less risk of hematoma. The mucosa is then closed using a running or running lock to the level of the hymeneal ring. The suture should have adequate depth to incorporate the rectovaginal septum but not deep enough to enter the rectum. slides 21, 22 The suture can then be brought out onto the perineal body. It can be used to close the perineal body, if necessary. Alternatively, the running suture can be tied inside the vagina proximal to the hymenal ring if the perineal body will be repaired with interrupted sutures for the transverse perineal slide 23 and bulbocavernosus muscles. If the depth exceeds 1-1.5 cm, deep interrupted sutures may be necessary to close the dead space and restore the perineal anatomy if a running suture was used. If interrupted sutures are the primary method of repairing the perineal body then deeper sutures will not be needed.

If a running suture was used then at this point the suture can be used to place the “crown stitch” or separate, interrupted 2-0 absorbable synthetic sutures can be used. The “crown stitch” is used to reapproximate the perineal body at the attachments of the bulbospongiosus muscles. It is intended to restore the introitus and bring the labia together. Care should be taken not to overly restrict or tighten the introitus. This can lead to dyspareunia.1

slide 24 The suture from the vaginal mucosal closure or the crown stitch can be used to close the perineal skin in a subcuticular fashion. A new stitch of 3-0 or 4-0 absorbable synthetic sutures can also be used. A Cochrane Review21 evaluating continuous versus interrupted skin sutures for perineal repair found that a continuous subcuticular technique was associated with less pain for up to 10 days post partum, reduction in analgesia use, reduction in dyspareunia and a decrease in the need for suture removal. There were no differences in the need for re-suturing of the wound, or long term pain. There was a greater reduction in pain when continuous suturing was used for all layers.

Several trials have investigated whether suturing of the perineal skin and/or muscles makes a difference for healing and postpartum pain. The SUNS trial24 evaluated the outcomes of primiparous women with first and second degree perineal lacerations, comparing those with repair of the muscle and skin to those without. The trial was limited by small sample size but found no difference between the two groups with regard to pain. There was a statistically significant difference in wound closure at six weeks, with 84 percent of the sutured group showing complete approximation, versus 44 percent for the unsutured group (P = 0.001) however it is unknown if this has any clinical relevance. The Ipswich Childbirth Studies25, 26 compared a 2-layer closure (leaving the skin edges unsutured) with a 3-layer closure. They found a trend toward decreased pain, decreased dyspareunia at three months, and less altered perineal sensation at one year in the 2-layer group compared to the 3-layer group. Oboro27 compared a 2-layer closure to a 3-layer closure and found patients with a 2-layer closure had less perineal pain at 48 hours (57 percent versus 65 percent, RR 0.87, CI 0.78, 0.97) and 14 days (22 percent versus 28 percent, RR 0.77, CI 0.61, 0.98), less need for suture removal, and less dyspareunia at three months. Rates of wound healing were similar. These studies would suggest that a 2-layer closure, leaving the skin edges unsutured, may be of patient benefit.

— Chapter N: Third and fourth Degree Perineal Lacerations — 7 Following the repair, care should be taken to assure all sponges have been removed from the vagina. A retained sponge can increase the risk for postoperative infection and repair breakdown. slide 25 Removal can be accomplished by a simple post procedure vaginal exam. A sponge count will ensure that all vaginal sponges have been removed. When removal is difficult, an Allis clamp can be passed along a finger and the sponge grasped. A postoperative rectal exam is recommended to assure that all rectal mucosal defects have been repaired and the rectal sphincter mass feels adequate. Optimally these exams were done after the repair of the rectal mucosa and external anal sphincter as the repair should not proceed if any layer has not been adequately reapproximated.

The final step in the performance of a repair is to write or dictate a good operative note. It should include a detailed description of the laceration, a summary of the steps taken to repair it and conclude with a statement about the post operative examination of the repair. A good concluding statement would be, “Post operative examination revealed the vaginal and perineal laceration to be well approximated without active bleeding or hematoma. The rectal exam revealed good sphincter approximation without defect and no palpable sutures or rectal defects.”

THE COMPLICATED REPAIR slide 26 No two lacerations are exactly the same. Some have lateral extensions and some have multidirec- tional extensions. Others may extend into the lateral vascular bundles giving rise to heavy bleeding. Some patients may have such extreme pain that they are unable to tolerate the repair under local or regional anesthesia. The clinician must be prepared to call for consultation if he or she is having difficulty with the repair or feels they lack the necessary expertise.

Timely consultation is extremely important especially in patients having excessive bleeding. Patients can quickly lose large volumes of blood through these lacerations and it is difficult for the clinician to measure this loss due to absorption from the drapes and sponges. The clinician should first expose the laceration and gain hemostasis. Suture ligatures with a 3-0 absorbable synthetic suture work well for this. If the upper limit of a sulcus laceration can not be visualized then place a suture as far into the vagina as possible and retract downward after. Once hemostasis is obtained, the repair can be completed as described above.

For those lacerations that extend in multiple directions, the clinician should first concentrate on those that are bleeding. The extensions should be closed in order of depth, with the deeper lacerations closed first and the superficial ones left for last. The clinician should attempt to close the rectal mucosa and anal sphincter as soon as hemostasis is obtained and deep lacerations are closed. Care must be taken not to close down the laceration and restrict exposure to the rectal mucosa and/or anal sphincter.

ANTIBIOTICS The use of a single, prophylactic dose of antibiotics at the time of a third or fourth degree repair has been recommended by many clinicians. A Cochrane review of antibiotic prophylaxis28 revealed one trial and found that a single, intravenous dose of a second generation cephalosporin did help to prevent perineal wound complications. However, the review stated that the results should be interpreted with caution because the findings are based on one trial with a high loss to follow up.

8 — — Chapter N: Third and Fourth Degree Perineal Lacerations slides 27-29 COMPLICATIONS It has been difficult to quantify the rates of complication from third and fourth degree lacerations due to the lack of uniformity in the literature in describing complications. Several studies provided individual rates which when combined gives a rough estimate of 15 percent for the complication rate of third and fourth degree laceration repairs.1 The most common complications are listed in Table 6.

Table 6. Complications of Third and Fourth Degree Laceration Repair1, 29

Anal incontinence Dehiscence Dyspareunia Hematoma Infection (superficial cellulitis, necrotizing fasciitis) Perineal abscess Rectrocutaneous fistula Rectovaginal fistula

The factors that lead to complications are numerous but the most common is breakdown secondary to infection.30 Poor approximations due to inadequate surgical technique or post operative hematoma can also result in severe complications. Table 7 lists many of the contributing factors for repair complications.

Table 7. Factors Contributing to Third and Fourth Degree Repair Complications26, 27 Anemia Blunt or penetrating trauma Cigarette smoking Connective tissue disease Constipation Endometriosis Forceful coitus Hematologic disease Hematoma Infection Inflammatory bowel disease Malnutrition Obesity Poor perineal hygiene Poor tissue approximation (poor surgical technique) Prior pelvic radiation

Although rare, necrotizing fasciitis of the perineum has such a high rate of morbidity and mortality that it deserves special note. Often occurring in patients with insulin-dependent diabetes, cancer or an immunosuppressive disorder, necrotizing fasciitis is a severe infection due to multiple bacterial pathogens, particularly anaerobes. It presents with a cyanotic discoloration of the wound with a loss of sensation. This infection should be managed aggressively with surgical debridement and broad- spectrum antibiotics.

— Chapter N: Third and fourth Degree Perineal Lacerations — 9 SUMMARY slide 30 Third and fourth degree perineal lacerations are common complications of all types of vaginal delivery but are dramatically increased in the presence of a midline episiotomy. These lacerations usually heal well when repaired appropriately in the absence of infection however a substantial proportion of patients will have long term anal incontinence symptoms (should be mentioned and ref- erenced earlier). Complications can occur and the most severe are rectovaginal fistula and necrotizing fasciitis. Patients who sustain these lacerations require closer observation and more aggressive treatment of wound infections. Most treatment is based on expert opinion; however, there is some evidence to guide the evaluation and treatment of these lacerations (Table 8).

PEARLS • Avoid episiotomy unless absolutely necessary. • The application of a warm pack (38 – 44 degrees C) to the perineum could be considered during the second stage of labor. • Consider instructing nulliparas patients to perform perineal massage starting at 36 weeks gestation. Support the perineum, especially in patients at high risk for a laceration. • If an operative delivery is necessary, the vacuum extractor is associated with less maternal morbidity than forceps. • Carefully exam all second degree lacerations as it is not uncommon to miss a third degree laceration • Use synthetic suture materials for perineal repair since they cause less maternal pain. • During the repair, build up the rectovaginal septum as much as possible (the greater the distance, the less likely a fistula will develop). • Hemostasis and good approximation of tissue planes are extremely important. • Examine your repair and if you find it is inadequate — redo it! • Stay vigilant for post operative infection and treat it aggressively. • Prescribe a stool softener postpartum for at least two weeks.

10 — — Chapter N: Third and Fourth Degree Perineal Lacerations Table 8. Summary of Evidence

Outcome % of women with Odds Ratio or NNT/ outcome Relative Risk (95% NNH** Vacuum Forceps Confidence Interval)

Significant maternal injury4 9.8% 20.3% 0.41 [0.33, 0.50] 10

Synthetic Catgut

Pain at 3 days18 54.3% 65.4% 0.62 [0.54, 0.71] 9

Analgesic use 18.4% 24.2% 0.63 [0.52, 0.77] 17

Suture dehiscence 2.9% 5.4% 0.45 [0.29, 0.70] 40

Suture removal 18.0% 10.1% 2.01 [1.56, 2.58] 13

Continuous Interrupted

Short term pain23 20.3% 27.3% 0.68 [0.53, 0.86] 14

Suture removal 26.0% 36.8% 0.61 [0.46, 0.80] 9

2-layer*** 3-layer

Perineal pain at 24-48 hours25 61.6% 64.0% 0.96 [0.90, 1.03] * Perineal pain at 10 days25 24.9% 27.6% 0.90 [0.77, 1.06] * Perineal pain at 1 year26 7.7% 10.4% 0.74 [0.55, 1.01] * Gaping at 10 days25 25.6% 16.4% 1.56 [1.30, 1.88] 11

Dyspareunia at 3 months25 15.4% 19.4% 0.80 [0.65, 0.99] 25

Area cut or torn feels different26 29.6% 39.6% 0.75 [0.61, 0.91] 10

*Since the 95% Confidence Interval includes 1.00, the result is not statistically significant and the NNH is not calculated. ** NNT is the number needed to treat; NNH is the number needed to harm. *** A 2 layer closer leaves the skin unsutured

— Chapter N: Third and fourth Degree Perineal Lacerations — 11 STRENGTH-OF-RECOMMENDATION (SORT) Category A 1. Episiotomy is associated with third and fourth degree lacerations.2, 7

2. The continuous subcuticular technique of perineal skin repair is associated with less pain in the immediate postpartum period and a reduction in analgesia and dyspareunia compared to the interrupted suture technique.1, 23

3. Use of the vacuum extractor rather than forceps for assisted delivery appears to reduce maternal morbidity.4

4. Absorbable synthetic suture material in the form of polyglycolic acid and polyglactin sutures for perineal repair following childbirth appears to decrease the women’s experience of short term pain. The length of time taken for the synthetic material to be absorbed is of concern.2, 19

5. Restrictive episiotomy policies appear to have a number of benefits compared to routine episiotomy policies. There is less posterior perineal trauma, less suturing and fewer complications, no difference for most pain measures and severe vaginal or perineal trauma, but there was an increased risk of anterior perineal trauma with restrictive episiotomy.2

Category B 1. Operative delivery (forceps>vacuum) increases the risk of third and fourth degree lacerations.8-9

2. A lateral delivery position has the highest association with an intact perineum at birth.13, 14

3. Anesthesia (local and epidural), increased second stage of labor, nulliparity, occiput transverse or occiput posterior positions, use of oxytocin and patient age less than 21 years old, increase the risk of third and fourth degree lacerations.8-9, 19, 21

4. A single, intravenous dose of a second generation cephalosporin can help prevent perineal wound complications.29

Category C The methods described for the repair of third and fourth degree lacerations represent available expert opinion.1

12 — — Chapter N: Third and Fourth Degree Perineal Lacerations REFERENCES 1. Episiotomy. In: Gilstrap LC, Cunningham FG, 14. Soong B, Barnes M. Maternal position at Midwife- Vandorsten JP, eds. Operative Obstetrics. 2nd ed. attended birth and perineal trauma: Is there an Connecticut: Appleton & Lange, 2002; 63-89. association? Birth 2005;32:164-169. [Evidence level 1, [Evidence level 2 & 3] Prospective cohort study] 2. Carroli G, Mignini L. Episiotomy for Vaginal Delivery. 15. Caroci da Costa ADS, Conzalez Riesco ML. A com- The Cochrane Database of Systematic Reviews 2009, parison of “hands off” versus “hands on” techniques Issue 1. [Evidence level 1, Systematic review] for decreasing perineal lacerations during birth. J 3. Rogers RG, Leeman LM, Migliaccio L, Albers LL. Does the Midwifery Womens Health 2006;51:106-111. [Evidence severity of spontaneous genital tract trauma affect post- level 1, RCT] partum pelvic floor function? Int Urogynecol J 2008;19:429- 16. McCandlish R, Bowler U, van Asten H, Berridge G, 435. [Evidence level 1, Prospective cohort study] Winter C, etal. A randomized controlled trial of care of 4. O’Mahony F, Hofmeyr GJ, Menon V. Choice of instru- the perineum during second stage of normal labor. Brit 1998;15:1262-72. [Evidence level 1, ments for assisted vaginal delivery. Cochrane Database J Obstet Gynaecol high quality RCT] of Systematic Reviews 2010, Issue 11. [Evidence level 1, Systematic review] 17. Andrews V, Sultran AH, Thakar R, Jones PW. Occult 5. Eason E, Labrecque M, Wells G, Feldman P. Preventing anal sphincter injuries – myth or reality. Brit J Obstet perineal trauma during childbirth: A systematic review. Gynaecol 2006;113:195-200. [Evidence level 1, Prospective cohort study] Obstet Gynecol 2000;95:464-71. [Evidence level 1, Systematic review] 18. Kettle C, Dowswell T, Ismail KMK. Absorbable suture 6. Dahlen HG, Homer CSE, Cooke M, Upton AM, Nunn R, materials for primary repair of episiotomy and second etal. Perineal outcomes and maternal comfort related degree tears. Cochrane Database of Systematic Reviews to the application of a perineal warm packs in the sec- 2010, Issue 6. [Evidence level 1, systematic review] ond stage of labor: A randomized controlled trial. Birth 19. Anderson RM, Romfh RF. Technique in the use of 2007;34:282-90. [Evidence level 1, High quality RCT] surgical tools. New York: Appleton-Century-Crofts, 1980. 7. Klein MC, Gauthier RJ, Robbins JM, et.al. Relationship [Evidence level 3] of episiotomy to perineal trauma and morbidity, sexual 20. Dencker A, Lundgren I, Sporrong T. Suturing after dysfunction and pelvic floor relaxation. Am J Obstet childbirth – a randomised controlled study testing a Gynecol 1994;171:591-8. [Evidence level 1] new monofilament material. BJOG 2006;113(1):114–6. 8. Landy HJ, Laughon K, Bailit JL, Kominiarek MA, [Evidence level 1, high quality RCT] Gonzalez-Quintero VH, etal. Characteristics associated 21. Hawkins JL, Goetzl L, Chestnut DH. Obstetric with severe perineal and cervical lacerations dur- Anesthesia In: Gabbe SG, Niebyl JR, Simpson JL, ing vaginal delivery. Obstet Gynecol 2011; 117:627-35. eds. Obstetrics: Normal & Problem Pregnancies. 5th [Evidence level 2, Retrospective cohort study] ed. New York: Churchill Livingstone, 2007; 396-427. 9. Combs CA, Robertson PA, Laros RK. Risk factors for [Evidence level 2 & 3] third-degree and fourth-degree perineal lacerations in 22. Fernando RJ, Sultan AHH, Kettle C, Thakar R, Radley forceps and vacuum deliveries. Am J Obstet Gynecol S. Methods of repair for obstetric anal sphincter injury. 1990;163:100-4. [Evidence level 2] The Cochrane Database of Systematic Reviews 2010, 10. Mahony R, Behan M, Daly L, Kirwan C, O’Herlihy C, Issue 2. [Evidence level 1, systematic review] etal. Internal anal sphincter defect influences conti- 23. Kettle C, Hills RK, Ismail KMK. Continuous versus inter- nence outcome following obstetric anal sphincter injury. rupted sutures for episiotomy or second degree tears. Am J Obstet Gynecol 2007;196:217.e1-217.e5. [Evidence The Cochrane Database of Systematic Reviews 2007, level 2, Prospective cohort study] Issue 4. [Evidence level 1, systematic review] 11. Farrell SA, Gilmour D, Turnbull GK, Schmidt MH, 24. Fleming VE, Hagen S, Niven C. Does perineal suturing Baskett TF, et.al. Overlapping compared with end-to-end make a difference? The SUNS trial. BJOB 2003;110:684- repair of third- and fourth-degree obstetric anal sphinc- 689. [Evidence level 2, lower quality RCT] ter tears. Am J Obstet Gynecol 2010;116:16-24. [Evidence 25. Gordon B, Mackrodt C, Fern E, et.al. The Ipswich level 1, high quality RCT] Childbirth Study: 1. A randomized evaluation of a two 12. Albers LL, Sedler KD, Bedrick EJ, Teaf D, Peralta P. stage postpartum perineal repair leaving the skin unsu- Midwifery care measures in the second stahe of labor tured. BJOB 1998;105:435-440. [Evidence level 1, RCT] and reduction of genital trauma at birth: A randomized 26. Grant A, Gordon B, Mackrodt C, et.al. The Ipswich trial. J Midwifery Womens Health 2005;50(5):365-72. Childbirth Study: one year follow up of alternative [Evidence level 1, high quality RCT] methods used in perineal repair. BJOB 2001;108:34-40. 13. Shorten A, Donsante J, Shorten B. Birth position, [Evidence level 1, RCT] accouchner and perineal outcomes: Informing women about choices for vaginal birth. Birth 2002;29:18-27. [Evidence level 2, Retrospective cohort study]

— Chapter N: Third and fourth Degree Perineal Lacerations — 13 27. Oboro VO, Tabowei TO, Loto OM, et.al. A multicenter evaluation of the two layered repair of postpartum perineal trauma. J Obstet Gynaecol 2003;23:5-8. [Evidence level 2, lower quality RCT] 28. Buppasiri P, Lumbiganon P, Thinkhamrop J, Thinkhamrop B. Antibiotic prophlaxis for third- and fourth-degree perineal tear during vaginal birth (review). The Cochrane Database of Systematic Reviews 2010, Issue 11. [Evidence level 1, lower quality RCT] 29. Legino LJ, Woods MP, Rayburn WF, McGoogan LS. Third- and fourth-degree perineal tears – 50 years’ experience at a university hospital. J Repro Med 1988;33:423-6. [Evidence level 2] 30. Homsi R, Daikoku NH, Littlejohn J, Wheeless CR. Episiotomy: Risks of dehiscence and rectovaginal fistula. Obstet Gynecol Surv 1994;49(12):803-8. [Evidence level 1, Meta-analysis]

14 — — Chapter N: Third and Fourth Degree Perineal Lacerations ® Chapter N: Perineal Lacerations

ALSO® Syllabus Update 2006

Evidence Review completed by Timothy P. Canavan, MD, MSc and Allan Wilke, MD Completed November 18, 2005 and Update published January 20, 2006 SUMMARY OF RECOMMENDATIONS Sort A • Vacuum assisted vaginal delivery results in a lower incidence of severe perineal trauma than forceps delivery.1 • For perineal repair, a synthetic absorbable suture is associated with less postpartum pain and need for analgesia than catgut suture.2 • A continuous subcuticular skin closure is associated with less pain and less need for suture removal compared to interrupted transcutaneous sutures and is preferred when the perineal skin is sutured.3

Sort B • A 2-layer closure, leaving skin edges unsutured, is preferred over a 3-layer closure because it is associated with a trend toward less pain and significantly less dyspareunia.5,6,7 There is an increased risk of gaping at 10 days post partum.5 • There is insufficient data to recommend any type of antibiotic prophylaxis for fourth degree laceration repair.8

A Cochrane Review1 of 10 trials found that, compared to forceps, the vacuum extractor was associated with less maternal trauma.

A Cochrane Review comparing absorbable synthetic with plain or chromic catgut suture for perineal repair included 8 trials of good quality and found that synthetic suture was associated with less pain in the first 3 days, less need for analgesia, and less suture dehiscence. There was no significant difference in long term pain or the amount of dyspareunia women experienced. Suture removal was significantly more common with synthetic suture.

A Cochrane Review evaluating continuous versus interrupted skin sutures for perineal repair found that a continuous subcuticular technique was associated with less pain for up to 10 days post partum and a decrease in the need for suture removal. There were no differences in the need for analgesia, re-suturing of the wound, or dyspareunia. Several trials have investigated whether perineal suturing makes a difference for healing and postpartum pain. The SUNS trial evaluated the outcomes of primiparous women with first and second degree perineal lacerations, comparing those with repairs to those without. The trial was limited by small sample size but found no difference between the two groups with regard to pain. There was a significant difference in wound closure at six weeks, with 84 percent of the sutured group showing completeapproximation, versus 44 percent for the unsutured group (P = 0.001). The Ipswich Childbirth Studies, compared a 2-layer closure (leaving the skin edges unsutured) with a 3-layer closure. They found a trend toward decreased pain, decreased dyspareunia at three months, and less altered perineal sensation at one year in the 2-layer group compared to the 3-layer group. Oboro compared a 2-layer closure to a 3-layer closure and found patients with a 2-layer closure had less perineal pain at 48 hours (57 percent versus 65 percent, RR 0.87, CI 0.78, 0.97) and 14 days (22 percent versus 28 percent, RR 0.77, CI 0.61, 0.98), less need for suture removal, and less dyspareunia at three months. Rates of wound healing were similar.

A systematic review on the use of antibiotic prophylaxis for fourth degree laceration repair8 found insufficient data to make any recommendations for practice.

— Chapter N: Third and fourth Degree Perineal Lacerations — 15 Chapter N: Perineal Lacerations, continued

Odds Ratio or Relative Risk Outcomes (%) of women with outcome NNT/NNH** (95% Confidence Interval) Vacuum Forceps

Significant maternal injury1 9.8% 20.3% 0.41 [0.33, 0.50] 10

Synthetic Catgut

Pain at 3 days2 54.3% 65.4% 0.62 [0.52, 0.71] 9

Analgesic use 18.4% 24.2% 0.63 [0.52, 0.77] 17

Suture dehiscence 2.9% 5.4% 0.45 [0.29, 0.70] 40

Suture removal 18.0% 10.1% 2.01 [1.56, 2.58] 13

Continuous Interrupted

Short term pain3 20.3% 27.3% 0.68 [0.53, 0.86] 14

Suture removal 26.0% 36.8% 0.61 [0.46, 0.80] 9

2-layer 3-layer

Perineal pain at 24-48 hours5 61.6% 64.0% 0.96 [0.90, 1.03] *

Perineal pain at 10 days5 24.9% 27.6% 0.90 [0.77, 1.06] *

Perineal pain at 1 year6 7.7% 10.4% 0.74 [0.55, 1.01] *

Gaping at 10 days5 25.6% 16.4% 1.56 [1.30, 1.88] 11

Dyspareunia at 3 months5 15.4% 19.4% 0.80 [0.65, 0.99] 25

Area cut or torn feels different6 29.6% 39.6% 0.75 [0.61, 0.91] 10

* Since the 95% Confidence Interval includes 1.00, the result is not statistically significant and the NNH is not calculated. NNT is the number needed to treat NNH is the number needed to harm

REFERENCES 1. Johanson RB, Menon V. Vacuum extraction versus forceps 5. Gordon B, Mackrodt C, Fern E, et.al. The Ipswich Childbirth for assisted vaginal delivery. The Cochrane Database of Study: 1. A randomized evaluation of a two stage postpartum Systematic Reviews 1999, Issue 2. [Evidence level 1, systematic perineal repair leaving the skin unsutured. BJOB 1998;105: review] 435-440. [Evidence level 1, RCT] 2. Kettle C, Johanson RB. Absorbable synthetic versus catgut 6. Grant A, Gordon B, Mackrodt C, et.al. The Ipswich Childbirth suture material for perineal repair. The Cochrane Database Study: one year follow up of alternative methods used in peri- of Systematic Reviews 1999, Issue 4. [Evidence level 1, system- neal repair. BJOB 2001;108:34-40. [Evidence level 1, RCT] atic review] 7. Oboro VO, Tabowei TO, Loto OM, et.al. A multicenter evaluation 3. Kettle C, Johanson RB. Continuous versus interrupted sutures of the two layered repair of postpartum perineal trauma. for perineal repair. The Cochrane Database of Systematic J Obstet Gynaecol 2003;23:5-8. [Evidence level 2, lower Reviews 1998, Issue 1. [Evidence level 1, systematic review] quality RCT] 4. Fleming VE, Hagen S, Niven C. Does perineal suturing make a 8. Buppasiri P, Lumbiganon P, Thinkhamrop J, et. al. Antibiotic difference? The SUNS trial. BJOB 2003;110:684-689. [Evidence prophylaxis for fourth-degree perineal tear during vaginal birth. level 2, lower quality RCT] The Cochrane Database of Systematic Reviews 2005, Issue 4. [Evidence level 2, systematic review finding insufficient trials]

16 — — Chapter N: Third and Fourth Degree Perineal Lacerations Chapter O Diagnostic Ultrasound in Labor and Delivery slide 1 Mark Deutchman, MD Tammy Myers, MD

Published August 2010 slide 2 OBJECTIVES After completing this chapter, participants will be able to: 1. Describe the indications for and types of ultrasound examinations in pregnancy including how limited scanning is useful in intrapartum care. 2. Describe and apply basic scanning techniques, including the transabdominal, transvaginal, and transperineal routes. 3. Perform basic labor and delivery applications of diagnostic ultrasound, including determination of fetal life, fetal number, fetal presentation, basic placental location, and amniotic fluid assessment. 4. Describe the components of a biophysical profile (BPP) and modified biophysical profile and understand the indications and limitations of the BPP in evaluating a patient with abnormal fetal surveillance testing. 5. Document ultrasound findings, and apply them to guide clinical management. 6. Discuss advanced applications in obstetrical ultrasound that require extended training and supervised practice. slide 3 INTRODUCTION Diagnostic ultrasonography is an essential tool in pregnancy management. Every health care provider caring for pregnant women can benefit from familiarity with ultrasound scanning, particularly when there is an urgent need on labor and delivery to determine fetal position, evaluate placenta location or determine if a fetal demise has occurred. Basic ultrasound skills help guide management decisions. These applications include determining fetal life, fetal number, fetal presentation, amniotic fluid status, and basic placental location. Those who wish to use available ultrasound equipment in their labor and delivery suites should become familiar with the equipment prior to the time they need to use it in the course of patient care. With additional advanced training and practice, basic biometry can be learned to determine fetal gestational age, a very useful skill when the patient with no prenatal care presents in labor. Advanced applications take considerable additional training and practice.

INDICATIONS slide 4 The majority of pregnant patients will develop one or more recognized indications for diagnostic ultrasonography during their pregnancy. The list of indications shown in Table 1 was developed by a National Institute of Health consensus conference in 1984, and has withstood the test of time.1 These indications have been reaffirmed by professional organizations including the American Institute of Ultrasound in Medicine (AIUM), American College of Radiology (ACR) and American College of Obstetrics and Gynecology (ACOG).2,3,4 Several of these indications arise in labor and delivery including diagnosis of fetal life, number, presentation, fluid assessment and placental localization.

— Chapter O: Diagnostic Ultrasound in Labor and Delivery — 1 Table 1. Indications for Obstetric Ultrasonography (adapted from NIH 1984)

• Gestational age assessment in cases of uncertain dates, termination of pregnancy, need for induction of labor, or repeat cesarean delivery before the onset of labor • Evaluation of fetal growth • Vaginal bleeding, rule out placenta previa • Determination of fetal presentation • Suspected multiple gestation • Adjunct to amniocentesis • Size-dates discrepancy • Maternal pelvic masses found clinically • Suspected hydatidiform mole • Adjunct to cervical cerclage placement or cervical length in cerclage patients • Suspected ectopic pregnancy • Adjunct to special procedures such as chorionic villus sampling • Suspected fetal death • Suspected uterine abnormality and evaluation of a cervical scar • Intrauterine contraceptive device localization • Ovarian follicle development surveillance • Biophysical evaluation for fetal well-being • lntrapartum events: to aid version of the second twin; guidance of manual placenta removal • Suspected polyhydramnios or oligohydramnios • Suspected placental abruption • Adjunct to external version from breech to vertex presentation • Fetal evaluation and weight estimation in cases of premature labor and premature rupture of the membranes • Investigation of abnormal serum alpha-fetoprotein • Follow-up observation of identified fetal anomaly • Repeat evaluation of placental location • History of a previous infant with a congenital anomaly • Serial evaluation of fetal growth in multiple gestation • Evaluation of the fetal age and condition when prenatal care has been started late or has not been sought prior to the onset of labor

Types of Ultrasound Examinations During Pregnancy slide 5 Professional o rganizations have also agreed on the types of ultrasound examinations and the standard content, nomenclature and required documentation.2,3,4 Table 2 contains a brief summary of those definitions and standards. By definition, labor and delivery ultrasound scans performed to answer specific clinical questions are “limited” examinations.

2 — — Chapter O: Diagnostic Ultrasound in Labor and Delivery Table 2. Types of Ultrasound Examinations: 2,3,4

Standard First-Trimester Ultrasound Examination includes a complete evaluation of the embryo, uterus and adnexae. Standard Second- or Third-Trimester Examination includes a complete evaluation of fetal presentation, amniotic fluid volume, cardiac activity, placental position, fetal biometry, and fetal number, plus a fetal anatomic survey. The maternal adnexae and cervix are examined as clinically appropriate when technically feasible. All standard examinations include these components. Terminology describing examinations as “Level I” or “Level II” etc. is obsolete. Limited Examinations are performed to answer a specific clinical question such as to confirm fetal heart activity in a bleeding patient, to verify fetal presentation in a laboring patient or assess amniotic fluid volume. Specialized Examinations include detailed anatomic examinations when an anomaly is suspected on the basis of history, biochemical abnormalities, or the results of either the limited or standard scan. Other specialized examinations might include fetal Doppler sonography and fetal echocardiography. slide 6 This chapter divides applications of limited examinations into “basic” and “advanced” based on how readily clinicians can usually learn them. Practicing clinicians with a base of knowledge in maternal- fetal anatomy and physiology often master the basic applications in a one-day workshop. Significant additional study and supervised practice is necessary to learn the advanced applications.5,6,7 Knowledge of ultrasound diagnosis by maternity care providers in labor and delivery is especially valuable in areas with limited access to hospital based sonographers.

LIABILITY Clinicians for whom sonographic information is urgently needed in the intrapartum setting may be concerned that inability to perform a standard examination may result in medicolegal liability, even though a limited scan may readily answer the clinical question at hand. In addition, scans performed in the labor and delivery setting may have technical limitations such as oligohydramnios or engagement of the fetal head, that prevent the performance of all the components of a standard examination. In urgent situations, limited scanning can provide answers needed to guide clinical management, improve patient care and decrease liability. Findings should be documented and incorporated into the clinical plan.

TECHNICAL CONSIDERATIONS Maternity care providers should familiarize themselves with the equipment available on the labor and delivery unit where they work. Features such as transducer selection, patient identification entry, gain and depth controls, freeze frame, electronic calipers for measurements, and image storage are most important. Table 3 defines some basic ultrasound terms and concepts for review. Written documentation should include indication and limited scope of the scan, findings, and management. Consultation should always be sought if findings are outside of the provider’s ability to diagnose or manage. A sample form for recording findings of a labor and delivery scan is included as Appendix 1.

— Chapter O: Diagnostic Ultrasound in Labor and Delivery — 3 Table 3. Diagnostic Ultrasound Terms and Physical Concepts

Transducers and image formation — Transducers are constructed from piezoelectric crystals. When a driving voltage is applied to a piezoelectric crystal, it vibrates, emitting sound energy. The same crystals detect returning, reflected sound energy and convert it to tiny electrical impulses. Computation of the timing and intensity of these impulses is made to display an image. Sequential firing of the crystals creates a two-dimensional “slice”, that when rapidly updated produces a moving “realtime” image. Scanning or transducer frequency — Transducers for transabdominal scanning in the third trimester are 3.0 MHz or 3.5 MHz. Many modern transducers are variable frequency permitting scanning at 5.0 MHz in earlier pregnancy and 3.0 MHz to 3.5 MHz later in pregnancy. Transvaginal transducers use higher frequencies (5.0 MHz to 7.0 MHz) for very early pregnancy scanning and assessment of the cervix and endocervical area. Higher frequency transducers produce improved resolution but have shallower depth of view. Power — Diagnostic ultrasound is sound energy. The energy output of diagnostic ultrasound scanners may be fixed or variable and is regulated by the United States Food and Drug Administration. If the power is variable, the lowest energy output that produces a readable image should be used. Gain and time gain compensation — Returning echoes are weak and must be amplified in general (overall gain) and selectively by depth within the image (time gain compensation or TGC) to produce a visible image. The gain controls are different from “brightness” controls on the video monitor. Gain controls must usually be readjusted between patients and when scanning different areas of the same patient to optimize the image. Acoustic windows — Sound waves must reach the object of interest before echoes can be reflected to produce an image. Fluids, such as urine and amniotic fluid, allow sound waves to pass freely, acting as “acoustic windows” to the structures beneath or within them Acoustic shadows — When adjacent tissues differ widely in density, strong echoes are produced and no sound is transmitted. Tissue-bone and gas-tissue interfaces are examples of areas that act like mirrors, reflecting nearly all the sound energy that strikes them and producing a shadow that conceals underlying structures. No amount of increased gain or power will enable the operator to see through such a mirror; instead the transducer position must be changed to avoid the obstruction. B-mode — “Brightness mode” is the normal mode in which two dimensional realtime scanning is performed. Echoes from structures within the body are displayed with varying degrees of brightness with depth on the vertical axis and width on the horizontal axis of the image. M-mode — This mode displays a single line of image on the vertical axis and time on the horizontal axis. It is useful to document motion, especially fetal cardiac motion. Doppler velocimetry — This modality measures the velocity of blood flow and displays it as a waveform. It is useful for measuring blood flow in uterine and fetal vessels, including the umbilical cord. The use of Doppler ultrasound in high risk pregnancies appears to improve a number of obstetric care outcomes and appears promising in helping to reduce perinatal deaths.14 Color Doppler imaging — This modality displays velocity and direction of blood flow within the image as color. An important example of application of this technique is the detection of fetal cardiac defects. Power Doppler imaging — This modality displays the volume of blood flow within the image as color without regard to its velocity or direction. This technique is useful for distinguishing one tissue from another and, for example, identifying umbilical cord within amniotic fluid.

4 — — Chapter O: Diagnostic Ultrasound in Labor and Delivery SCANNING TECHNIQUES slides 7-10 This chapter provides background information on common labor and delivery applications of diagnostic ultrasonography. Scanning techniques for the basic applications are introduced in the optional workshop portion of this course. Advanced applications require additional training, techniques and practice. Using the equipment available on the labor and delivery unit with a variety of patients is necessary to develop skills. The suggested procedures described here can be used to guide performance of the basic labor and delivery applications both in workshop practice scanning and in clinical practice.

Transabdominal scanning can be done in any trimester and during labor. Limitations include fetal position, decreased amniotic fluid (oligohydramnios) with loss of acoustic window, fetal crowding at advanced gestational age, low fetal station, or maternal body habitus. 1) Position the patient for comfort; a left lateral tilt can decrease the incidence of supine hypotension. Discuss the reason for, and scope of, the examination. 2) Turn the ultrasound machine on and enter the patient’s name, date and other identifying information. 3) Apply scanning gel to the transducer scanning surface and/or the patient’s abdomen and hold the transducer so that the image is oriented properly on the video screen. By convention, scanning is performed with the examiner on the patient’s right side. Transducer position and image orientation are described relative to the maternal body, not to the body of the fetus. While scanning in a sagittal plane, the mother’s head is off the left side of the screen and her feet are off the right side of the screen. While scanning in a transverse plane, the mother’s right shoulder is off the left side of the screen and her left shoulder is off the right side of the screen, viewed as if standing at her feet and looking up towards her head. This convention is the same as that used for other cross-sectional imaging techniques such as CT and MRI. 4) Make necessary gain and depth adjustments while performing a series of longitudinal and transverse sweeps of the maternal abdomen viewing all quadrants of the uterus to note: a) fetal cardiac motion b) number of fetuses c) fetal lie, presentation and position d) quantity of amniotic fluid, performing an amniotic fluid index if desired e) basic placental location 5) During the course of the examination, record labeled images of significant findings for the medical record and, when finished, make a written record of findings and plan. Discuss findings and plan with the patient.

Transvaginal scanning is essential during the first trimester to adequately visualize the uterus, adnexae, cul-de-sac, early gestational sac and embryo (see Chapter A. First Trimester Complications). Transvaginal scanning is also useful during the second and third trimesters to visualize the cervix and endocervical area in cases of preterm labor, incompetent cervix and placenta previa. Skill in transvaginal scanning is NOT considered to be a “basic” skill that can be learned in the workshop associated with this course.

— Chapter O: Diagnostic Ultrasound in Labor and Delivery — 5 These features apply to transvaginal scanning: 1) Following discussion of the reason and scope of the examination, the patient is placed in lithotomy position. 2) Scan gel is applied to the tip of the transvaginal transducer, which is then covered with a clean or sterile condom or glove. Lubricating gel is applied over the cover and the transducer tip is introduced into the vagina. Sonographic visualization starts as soon as the transducer is introduced. Inserting the transducer tip too far can cause the examiner to miss seeing the cervix and lower uterine segment as the transducer tip reaches the posterior or anterior fornix. 3) Gain and depth controls are adjusted, and the transducer tip is positioned to obtain whatever sagittal, coronal or oblique views are necessary to visualize the structures. The vaginal opening acts as a fulcrum making it necessary to move the transducer handle toward the opposite side of the body that the examiner wishes to visualize. For example, to view the left adnexal area, the transducer handle is moved to the patient’s right, and to look toward the bladder, the handle is dropped toward the patient’s rectum. 4) By convention, transvaginal images are oriented like transabdominal images. In the sagittal plane, the mother’s head is off the left of the screen and feet are to the right. In coronal planes, the mother’s right shoulder is off the left of the screen and left shoulder is off the right side of the screen.

Scanning by the transperineal route is a useful alternative to transvaginal scanning during the second and third trimesters to visualize the cervix and endocervical area. This can be particularly helpful in cases of preterm labor, incompetent cervix and suspected placenta previa, as the vagina is not entered. Although the same transducer is used in the transperineal scan as in the transabdominal scan, a wider field of view is obtained than when a transvaginal transducer is used. A potential disadvantage is less detailed resolution than transvaginal scanning affords. Skill in transperineal scanning is NOT considered to be a “basic” skill that can be learned in the workshop associated with this course.

These features apply to transperineal scanning: 1) Following discussion of the reason and scope of the examination, the patient is placed in lithotomy position. 2) Scan gel is applied to the scanning surface of the transabdominal transducer, which is then covered with a clean or sterile glove. Lubricating gel is applied over the glove and the transducer face is placed up against the introitus and perineum. 3) Gain and depth controls are adjusted, and the transducer is positioned to obtain whatever sagittal, coronal or oblique views are necessary to visualize the area of interest. During transperineal scanning, the vagina appears as a bright line usually meeting the cervix at a 90-degree angle. The distance from the perineum to the cervix usually places the cervix at an ideal distance within the focal zone of the transducer. 4) Transperineal images are oriented like transvaginal images.

6 — — Chapter O: Diagnostic Ultrasound in Labor and Delivery BASIC APPLICATIONS slide 11 Basic applications are rapidly learned my most providers and facilitate gathering important information about the well being of the fetus. These include determining that the fetus is alive by visualizing the heartbeat, diagnosing fetal number, visualizing fetal lie, presentation, making a quantitative assessment of amniotic fluid volume, and determining basic placental location.

Fetal Life: slides 12-15 It is not uncommon for a patient to present with decreased or absent fetal movement. If a fetal heartbeat is not heard by auscultation or Doppler, or are outside the parameters of normal, then determining fetal life is a critical first step in management. During realtime scanning, the presence or absence of cardiac motion is usually apparent to both the examiner and the patient. Cardiac activity can be documented on a still image with the use of an M-mode tracing. Sonographic characteristics of fetal death are listed in Table 4. If the findings are in doubt, consultation should be obtained before offering a final diagnosis of fetal death. When fetal death is diagnosed, the approach to the patient and family must be individualized, but maintain communication and avoid medical jargon. After stating simply and directly the fact that the baby has died, it is best to interrupt further examination and allow the patient and family the opportunity to react to the news. Offer them the chance for some private time before proceeding with the collection of additional data, imaging or explanations. The chapter on birth crisis offers additional guidance on dealing with stillbirth.

Table 4. Sonographic Features of Fetal Demise

• Absence of cardiac motion • Hydropic changes (skin and subcutaneous edema, pleural and pericardial effusions, placental edema) • Abnormal lie • Overlapping skull bones • Oligohydramnios is common, but polyhydramnios may also be present depending on the underlying pathology

slides 16, 17 Fetal Number: A surprise twin at delivery should be a rarity. Although it may seem straightforward to determine fetal number with ultrasound, missing a twin is not unheard of. The sonographer must have a structured approach while scanning all four quadrants in longitudinal and sagittal planes. Two separate heads, spines, and heart beats should be visualized before making the diagnosis of twins. The fetal spine should be followed from the head to the sacrum, and the fundus should be evaluated for fetal parts. The false diagnosis of twins can be equally problematic. This can occur when the same structure such as head or heartbeat is viewed from two different angles. When the diagnosis is in doubt, consultation is necessary. If more than one fetus is seen, be sure to look further to avoid missing higher order multiples.

slides 18-21 Fetal Presentation, Lie and Position: Abnormal fetal presentation, lie or position are common in labor. (See Chapter G. Malpresentations) Leopold’s maneuvers and vaginal palpation can usually, but not always confirm this. Ultrasound can be definitive to determine presentation and guide clinical decision making. Table 5 defines the terms related to fetal orientation.

— Chapter O: Diagnostic Ultrasound in Labor and Delivery — 7 Table 5.Terminology of Fetal Orientation

• Presentation fetal part located over the maternal pelvic inlet (e.g. cephalic, breech) • Lie orientation of the fetal spine to the maternal spine (e.g. longitudinal, transverse, oblique) • Position orientation of presenting fetal part to the maternal pelvis (e.g. occiput anterior, sacrum anterior)

By making a series of both longitudinal and transverse sweeps of the maternal abdomen, the presentation, lie and position are usually quite clear. If the fetal lie is transverse and the patient is in labor, it is helpful to know if the spine is up or down in relation to the lower uterine segment. The risk of cord prolapse increases if the spine is up and delivery at cesarean may be difficult when the spine is down. Identifying the position of the spine may affect the choice of a uterine incision at the time of cesarean delivery.

Some details of fetal presentation, including compound presentations, cord presentations, and nuchal cord, may be very difficult or impossible to visualize. A single radiograph of the maternal abdomen is an acceptable diagnostic modality for diagnosis of fetal presentation, and may yield more detailed information than ultrasonography about the position of the fetal limbs and degree of flexion of the fetal head. If cord presentation or vasa previa is suspected, color or power Doppler may be indicated to rapidly clarify the diagnosis since blood flow will be readily detected.

Basic Placental Location: The differential diagnosis of late pregnancy bleeding includes placenta previa and abruption. (See slide 22 chapter C. Vaginal Bleeding in Late Pregnancy) For the patient who presents with this complication, a rapid diagnosis is essential but should never delay delivery, if indicated, for an unstable patient or fetus. Determining placental location is also important prior to cesarean delivery, particularly if a low anterior placenta was previously diagnosed or suspected. Placenta previa or implantation over a previous scar dramatically increases the likelihood of abnormal placental attachment (placenta accreta, increta, percreta) and the patient’s risk for severe hemorrhage and need for cesarean hysterectomy. The placenta is typically more echogenic than the myometrium, but uterine contractions can alter the apparent location, appearance, and thickness of the placenta in relation to the endocervical area. Crowding and oligohydramnios can make it difficult to visualize the placenta. Posterior locations are obscured by acoustic shadows of the fetus, and succenturiate lobes may be difficult to find. Examination for placenta previa and abruption are fraught with difficulty and is NOT considered a basic application.

Placental abruption can also present with vaginal bleeding and is an obstetrical emergency that is largely a clinical diagnosis. Ultrasound can be an adjunctive diagnostic tool, but as with placenta previa ultrasound should never delay clinically indicated treatment. Even in experienced hands, ultrasound can miss over 50 percent of placental abruptions, but does have a high positive predictive value when diagnosed sonographically.

8 — — Chapter O: Diagnostic Ultrasound in Labor and Delivery Amniotic Fluid Assessment slide 23 The ability to determine either a subjective or objective adequacy of amniotic fluid has many applications. Amniotic fluid is a function of placental health as well as fetal well being. Several obstetrical complications as well as fetal anomalies can cause either a high (polyhydramnios) or low (oligohydramnios) amniotic fluid volume. Techniques of quantitative amniotic fluid assessment include either an AFI (amniotic fluid index) or determination of deepest pocket. Table 6 includes definitions of quantitative amniotic fluid assessment. slides 24-27 Table 6. Amniotic Fluid Quantitative Assessment Terminology

Amniotic Fluid Index (cm) Deepest Pocket (cm)

Oligohydramnios4 < 5 < 2

Borderline (equivocal) 5 to 8 n/a

Normal 8 to 23 3 to 7

Polyhydramnios4 > 24 > 8

Assessment of amniotic fluid volume is an essential part of biophysical testing, and can provide ancillary evidence of prior membrane rupture. To perform an amniotic fluid index (AFI), the largest vertical pocket of amniotic fluid in each of the four quadrants of the uterus is measured and the sum computed. The transducer should be perpendicular to the floor, and the measured pockets should not contain umbilical cord or fetal extremities.

Measurement of the deepest pocket is done by identifying the single largest pocket of fluid free of cord or fetal parts. The vertical diameter relative to the transducer should measure at least 2 cm. The transducer should be rotated 90 degrees in the same axis to confirm a true three-dimensional pocket before measuring. The single deepest pocket has become the preferred technique because of higher specificity over AFI.8

Oligohydramnios in a postdate pregnancy is an indication for further testing or delivery. Mild to moderate polyhydramnios is common, usually idiopathic, and strongly associated with gestational diabetes. More severe polyhydramnios is a potent indicator of fetal anomalies including central nervous system defects, gastrointestinal defects and skeletal dysplasias. slides 28-30 ADVANCED APPLICATIONS Biophysical Assessment: 9,10 There are many indications for assessing fetal well being in pregnancy as discussed in Chapter E. Fetal surveillance can be accomplished using multiple techniques including the nonstress test (NST), contraction stress test (CST), modified biophysical profile (MBPP), and biophysical profile (BPP). Of these, the MBPP and BPP require readily learned ultrasound skills. The NST is a well described and often the first line method of fetal surveillance and is also discussed in detail in Chapter E. Definition of reassuring is based on NICHD criteria11 of a minimum of two episodes of acceleration > 15 beats per minute lasting > 15 seconds in a period of 30 minutes. The NST alone has a high false-positive (nonreassuring) rate which can lead to unnecessary intervention.

— Chapter O: Diagnostic Ultrasound in Labor and Delivery — 9 The first fetal biophysical parameter to become compromised in the presence of fetal acidemia is the last to manifest as the fetus matures. In other words, the most primitive brain functions are the last to be compromised. Fetal tone is the earliest (most primitive) biophysical parameter; it can be identified as early as eight weeks gestational age. Fetal body movement follows about one to two weeks later. Fetal breathing is detectable by 21 weeks gestational age, but fetal heart rate reactivity is not well established until 28 to 32 weeks. Compromised fetal heart rate reactivity is therefore the most sensitive marker of acute fetal acidosis. As the insult becomes more profound and chronic, fetal breathing, then body movement, then tone are compromised. Amniotic fluid volume is considered a marker of placental perfusion, and therefore decreased fluid considered a marker of chronic vascular compromise. Table 7 summarizes these concepts. Using these concepts and combining the NST with a MBPP or BPP can significantly improve the predictive value of the test as a marker for fetal well being.

Table 7. Biophysical Parameters Sensitivity to Acute Hypoxia

Component Process Assessed Type of Indicator

Fetal Tone CNS, cortex/subcortical least sensitive acutely

Fetal Movement CNS, ventral fourth ventricle intermediate, acute

Fetal Breathing CNS, post.hypothalamus, medulla intermediate, acute

Nonstress Test CNS, cortex/nuclei most sensitive acutely

Amniotic Fluid Quantity Uteroplacental/fetal perfusion chronic indicator

slide 31 MODIFIED BIOPHYSICAL PROFILE (MBPP):12 A MBPP is a NST (marker of acute fetal status) along with an amniotic fluid assessment (marker of chronic fetal status). A reactive NST combined with a 2 cm or greater deepest pocket of amniotic fluid is very reassuring of fetal well being and compares favorably with the complete biophysical profile. However, if the NST does not meet criteria for reactive and/or oligohydramnios is present, further fetal testing is indicated and delivery may be considered, especially near term.

BIOPHYSICAL PROFILE (BPP): slide 32 The biophysical profile (BPP) is another method of predicting antepartum fetal acidemia. Although the test can be used as a primary method of fetal surveillance, it can be especially helpful in cases where the NST is not reactive. There is some evidence that the BPP may even be useful during labor as an adjunct to fetal heart rate monitoring.13 The five components of a BPP integrate fetal cardiac activity, amniotic fluid assessment, fetal breathing, fetal movement and tone. Each component is scored 2 if present or reassuring and 0 if abnormal. Fetal breathing is probably as reliable as the NST in predicting early fetal acidosis. A BPP can be performed as early as 26 to 28 weeks gestation. The test can be completed in as little as five minutes if the fetus is active and awake, or can take as long as 30 minutes. Acoustic stimulation is appropriate to use to shorten the time of the study. Table 8 includes criteria for each component of the BPP.

10 — — Chapter O: Diagnostic Ultrasound in Labor and Delivery Table 8. Biophysical Profile

Parameter Score

NONSTRESS TEST 2 Two or more accelerations with fetal movement in 30 minutes 0 < 2 accelerations in 30 minutes

AMNIOTIC FLUID VOLUME 2 Largest pocket > 2 cm in vertical diameter 0 Largest pocket > 2 cm in vertical diameter, crowded fetal small parts

FETAL BREATHING 2 > 1 episode of fetal breathing lasting > 30 seconds withint 30 minutes, or hiccups 0 None, fetal breathing lasting < 30 seconds

FETAL MOVEMENT 2 > 3 gross movements (trunk and limbs) in 30 minutes 0 None or < 3 gross movements in 30 minutes

FETAL TONE 2 One episode extension of extremity or spine with return to flexion 0 Extension only, or movement not followed by return to flexion, or open hand

The maximum BPP score is 10. A score > eight is considered reassuring with a low risk of fetal slide 33 asphyxia within one week. A score of six is equivocal, and a score < four is abnormal with a significantly higher risk of fetal asphyxia within one week. However, not all components of the BPP are considered equal. Oligohydramnios, when not associated with ruptured membranes, is a marker for placental dysfunction and chronic fetal hypoxemia or acidemia and may require further action or more frequent surveillance, regardless of the total BPP score. On the other hand, if the amniotic fluid volume is normal, but the NST is not reactive, the presence of fetal breathing predicts reassuring fetal status.

slide 34 Doppler Velocimetry Measurement of vascular resistance in various parts of the fetal circulation have been found to be useful adjuncts in the investigation and management of pregnancy complications including, but not limited to, intrauterine growth restriction and fetal cardiac anomalies. A detailed discussion of Doppler velocimetry of the uteroplacental and fetal circulation is beyond the scope of this chapter. Doppler velocimetry has not been found to be efficacious in screening otherwise low risk pregnancies.14 slides 35-39 Estimation of Gestational Age (basic fetal biometry): A patient who presents in her first trimester with vaginal bleeding, cramping, undetectable fetal heart tones by Doppler despite estimated gestational age > 12 weeks by last menstrual period, or other size-date discrepancies will benefit from an ultrasound to estimate gestational age. The most accurate dating is done by ultrasound in the first trimester and ultrasound is more accurate in predicting true gestational age than last menstrual period during this time.15 Measurement of the gestational sac and embryo are discussed in Chapter A on First Trimester Pregnancy.

— Chapter O: Diagnostic Ultrasound in Labor and Delivery — 11 A crown-rump length is determined by measuring the maximal straight line distance from the fetal head to the rump. This measurement will estimate gestational age to within one week if done between seven and 13 weeks gestation. After 14 weeks gestation, fetal age is best determined by multiple biometric parameters including the fetal biparietal diameter, head circumference, abdominal circumference, and femur length. In the early second trimester, biometry is accurate to within two weeks, but confidence limits widen significantly in the third trimester due to normal individual variation. Confidence limits for gestational age assessment during the late third trimester are plus or minus four weeks, although still might be helpful in managing a patient presenting to labor and delivery without prenatal care. To be accurate, all fetal measurements must be made properly according to two criteria. First, the correct anatomic plane must be identified. Second, measurements must be made at the proper landmarks within that plane. The proper planes and landmarks are shown in the accompanying diagrams and images in the slide set. Fetal crowding, oligohydramnios and low station of the head can make the acquisition of accurate data very difficult in the laboring patient. Most ultrasound machines are programmed to calculate gestational age based on measured parameters. Published standard biometric tables can also be used such as those shown in Table 9 for the last half of pregnancy.

Table 9. Second and Third Trimester Biometric Measurements During the Last Half of Pregnancy (Adapted from Ultrasonography in Obstetrics and Bynecology, 5th edition 2007 Peter Callen; Philadelphia, PA: Elsevier Saunders)

BPD = biparietal diameter FL = femur length HC= head circumference AC = abdominal circumference Gestational age (wks) BPD(mm) FL(mm) HC(mm) AC(mm)

24 59 43 220 195 25 61 45 230 205 26 64 48 240 215 27 67 50 250 225 28 70 53 258 235 29 72 55 265 248 30 75 57 275 258 31 77 60 283 270 32 80 62 290 280 33 82 64 298 290 34 85 66 305 300 35 87 68 313 310 36 89 70 320 320 37 91 72 326 330 38 93 74 333 340 39 96 76 340 350 40 98 78 345 360

12 — — Chapter O: Diagnostic Ultrasound in Labor and Delivery slide 40 Estimation of Fetal Weight: Sonographic fetal weight estimates are calculated from biometric parameters using software programmed into the ultrasound machine or from nomograms in standard textbooks. Such estimates are often off by 500 grams or more during the third trimester and commonly overestimate birth weight.16 The positive predictive value for diagnosis of fetal macrosomia in postdates pregnancies, using standard equations, is only about 50 percent.17 Fetal weight estimation may be more critical in the management of diabetic pregnancies, which are complicated by a higher rate of shoulder dystocia at all birth weights greater than 3000 grams. Even in the diabetic pregnancy, the ability to detect macrosomia is limited, with best results obtained from methods using the abdominal circumference and femur length.18 Since the positive predictive value of ultrasound is low in detecting macrosomia, its use should be discouraged as a means of determining the route or timing of delivery for non- diabetic women with term or postdates pregnancies. There is evidence that sonographic diagnosis of macrosomia influences physician behavior in the management of labor. The use of retrospective cohort studies comparing pregnancies with a false positive diagnosis of macrosomia (estimated fetal weight greater than 4000 grams) and true negatives demonstrate significantly increased rates of cesarean delivery19,20,21 (up to 50 percent), and failed induction, without significant reduction in shoulder dystocia.22 Limited data from a single randomized controlled trial suggest that induction of labor in women with gestational diabetes treated with insulin reduces the risk of macrosomia.23

slides 41, 42 Cervical Length Determination: Scanning by the transperineal or transvaginal route may be useful to assess cervical length, to detect funneling and dilatation of the cervix, and to detect bulging membranes in patients with suspected preterm labor or cervical incompetence. Transvaginal ultrasound measurement of cervical length (TVU CL) can be a reliable predictor of spontaneous preterm birth.24-26 However, a Cochrane review of five randomized controlled trials looked at the effectiveness of TVU CL screening and concluded that there is insufficient evidence to recommend routine screening of either symptomatic or asymptomatic women to prevent preterm birth.27 A small randomized trial of 100 women with threatened preterm labor found that knowledge that the cervical length was > 3.0 allowed for a more rapid assessment and discharge, but further study is needed28.

slide 43 Guidance for External Cephalic Version: External cephalic version of the fetus from breech or transverse to cephalic presentation is discussed in Chapter G on Malpresentations, including a discussion of parameters that affect success. A complete ultrasound scan, including biometry and anatomic survey, should be done prior to cephalic version, as the incidence of anomalies is higher with breech presentation. Cord presentation should be ruled out and may be aided by color or power Doppler technique. Ultrasound is useful during the version procedure to monitor the changing fetal position and to visualize the fetal heartbeat.

Examination for Placenta Previa Placenta previa can be difficult to diagnose sonographically, depending on the location of the pre- slides 44, 45 senting part, the quantity of amniotic fluid, and the amount of urine in the maternal bladder. If the maternal bladder is overdistended, the lower uterine segment may be compressed, creating a false impression of placenta previa. Ultrasound evaluation of the lower uterine segment for possible placenta previa is best performed first with the bladder partially filled and then with an empty bladder. If possible, it should be performed during an interval without uterine contractions.

— Chapter O: Diagnostic Ultrasound in Labor and Delivery — 13 The lower uterine segment can be very effectively visualized by the transperineal route using a glove- covered 3.0 or 3.5 MHz transducer placed at the introitus or on the perineum. Careful transvaginal scanning with a 5.0 MHz or a 7.5 MHz transducer may be undertaken. Technical aspects of transvaginal and transperineal scanning are discussed in the section on “scanning techniques” above.

Examination for Placental Abruption slides 46, 47 Placental abruption may have a variable sonographic appearance depending on its age. The amount of bleeding is often underestimated. Fresh hemorrhage may appear as a sonolucent area between the uterine wall and the placenta, or in the substance of the placenta. Clotted blood may exhibit echogenicity similar to that of placental tissue. Non-pathologic venous lakes and marginal sinuses can have a similar appearance. Abruption may also present as an abnormal thickening or rounding of the placental edge, presumably from a marginal separation. The sonographic diagnosis of abruption should be incorporated into available clinical information to arrive at a management plan. Chapter C. on Vaginal Bleeding in Late Pregnancy includes more discussion on clinical management options in cases of abruption. The failure to diagnose abruption sonographically in a suspected clinical setting DOES NOT EXCLUDE THE DIAGNOSIS. Therefore, the provider should not change management based on a negative ultrasound scan alone.

Anatomic Survey for Anomalies Skill in performance of the anatomic survey for fetal anomalies requires significant additional train- slide 48 ing and supervised experience beyond that which can be accomplished in the workshop associated with this course. The standard antepartum ultrasound examination includes a comprehensive survey of fetal anatomy as agreed upon by several professional organizations. Attention to the items in this survey will detect most, but not all, fetal anomalies depending on gestational age. It is common for the patient to ask: “Is my baby all right?” during a limited labor and delivery scan. The examiner will then need to stop and explain what the goals and limitations of the examination are and what he or she can and cannot, diagnose on the basis of the examination being performed. Often, the patient will have had an earlier examination that included a standard survey of fetal anatomy that provides reassurance. If clinical questions exist about the presence of fetal anomalies, a standard examination that includes an anatomic survey should be performed when time and conditions permit. lntrapartum Twin Management slide 49 The intrapartum management of twins in the delivery room can be facilitated by assessing the initial presentation and lie of the fetuses. Following delivery of the first twin, ultrasound may be used to observe the cardiac rate and rhythm of the second twin and to guide the second twin into the cephalic presentation for delivery. The technique is the same as that described for external cephalic version and should be kept in mind for cases of unanticipated as well as planned twin delivery. Alternatively ultrasound may be used to determine the location of the feet when the second twin is in a transverse presentation and breech extraction or internal podalic version is planned.29

Amniocentesis Guidance slide 50 Ultrasound guidance can facilitate amniocentesis for lung maturity testing and to rule out amnionitis. In cases of preterm labor, such information may guide decisions about transfer from hospitals without neonatal intensive care facilities. Sonographic guidance aids in locating a pocket for sampling which is free of umbilical cord, away from the fetal face, and not directly underneath the placenta. Alternatively, the fetal head may be lifted abdominally after the maternal bladder has been emptied,

14 — — Chapter O: Diagnostic Ultrasound in Labor and Delivery leaving a pocket of fluid, which may be tapped suprapubically. This latter technique may, in some cases, result in rupture of membranes. Continuous sonographic observation of the amniocentesis needle makes the procedure safer. slide 51 Perspective on Routine Scanning During Pregnancy This chapter has dealt with specific indications and techniques for limited sonographic examination mostly during late pregnancy and in the labor and delivery setting. It has not addressed the issue of the value of routine scanning for all pregnant patients. A detailed exposition of this topic is beyond the scope of this chapter. This issue continues to be debated, and is complicated by significant regional and international differences in practice patterns and patient populations. A variety of clinical benefits have been ascribed to routine ultrasound examination of all pregnant patients, some of which are supported by high quality evidence. Routine early pregnancy ultrasound examination before 24 weeks and subsequent adjustment of delivery date appear to reduce the incidence of post-term pregnancy30 and postdates induction. More accurate gestational dating can facilitate routine induction of labor at 41 weeks which appears to reduce perinatal mortality.31 Ultrasound done in early pregnancy before 24 weeks appears to provide better gestational age assessment and earlier detection of multifetal pregnancy.30 Scanning pregnancies after 24 weeks in unselected and low-risk populations does not reduce perinatal mortality or confer other benefits.32 slide 52 Routine second trimester anatomic survey, although commonly performed in developed countries, has not been demonstrated to improve perinatal outcomes. A detailed anatomic survey may be indicated due to abnormal serum screening, advanced maternal age, personal or history of fetal anomalies or exposures to teratogenic agents. Detection of major anomalies or genetic conditions may help patients and families become emotionally prepare for anomalies and facilitate choice of optimal delivery site. Identification of anomalies and genetic conditions in the second trimester allows option of pregnancy termination.

The American College of Obstetricians and Gynecologists (ACOG) recognizes the importance of accurate pregnancy dating and fetal anatomic survey although stops short of recommending routine screening ultrasound for all patients. ACOG and the American Academy of Family Physicians (AAFP) also take the position against non-medically indicated, or recreational, ultrasound and view this practice as inappropriate and contrary to responsible medical practice.33-34

SUMMARY slide 53 All clinicians who deliver babies can benefit from learning the basic applications of diagnostic ultrasound in labor and delivery. The ability to rapidly assess fetal life, fetal number, fetal presentation, quantity of amniotic fluid, and basic placental location may be learned rather quickly, and can have significant bearing on clinical management. Advanced applications require further study and practice. Frequent use of the basic applications will help maintain proficiency while keeping in mind the shortcomings, complicating factors, and potential pitfalls of labor and delivery scanning.

— Chapter O: Diagnostic Ultrasound in Labor and Delivery — 15 SUMMARY TABLE OF RECOMMENDATIONS Category A Routine pregnancy ultrasound examination before 24 weeks, with subsequent adjustment of delivery date if indicated, appears to reduce the incidence of post-term pregnancy30 and facilitate induction of labor at 41 weeks to reduce perinatal mortality.31 Routine ultrasound scanning before 24 weeks improves recognition of clinically unsuspected multifetal pregnancy.30 Routine ultrasound scanning after 24 weeks in unselected low-risk patients does not reduce perinatal mortality.32 The use of Doppler ultrasound in high risk pregnancies with hypertensive disease or fetal growth restriction appears to improve a number of obstetric care outcomes and appears promising in helping to reducing perinatal deaths.14

Category B Ultrasonographic estimates of fetal weight should not be used to determine route of birth in nondiabetic pregnancies.19,20,21 The modified biophysical profile (MBPP) or biophysical profile (BPP), along with NST and CST, are appropriate methods of antepartum fetal surveillance in high risk patients.10,12 An abnormal NST or MBPP should be further evaluated with a CST or full BPP.10,12

Category C Maternity care providers can learn the basic sonographic skills in a short time. Sonographic applications including fetal biometry, anatomic survey, examination for placental abruption and previa, and assessment of the cervix are extended skills that require significantly more study and practice than the basic skills.5,6,7

16 — — Chapter O: Diagnostic Ultrasound in Labor and Delivery REFERENCES 1. National Institutes of Health Consensus Panel on 18. Pollack RN, Hauer-Pollack G, Divon MY: Macrosomia in post- Ultrasonography in Obstetrics. NIH 1984 Government Printing dates pregnancies: the accuracy of routine ultrasonographic Office. (Level III) screening. Am J Obstet Gynecol Jul, 1992;167(1):7-11. (Level III) 2. American Institute of Ultrasound in Medicine Standards 19. McLaren RA, Puckett JL, Chauhan SP: Estimators of birth for Performance of the Antepartum Obstetrical Ultrasound weight in pregnant women requiring insulin: a comparison of Examination 2000 AIUM, Laurel MD. http://www.aium.org/ sonographic models. Obstet Gynecol Apr, 1995;85(4):565-9. publications/guidelines/obstetric.pdf accessed 4/9/2010 (Level III) (Level III) 20. Levine AB, Lockwood CJ, Brown B, Lapinski R, Berkowitz 3. American College of Radiology. ACR practice guideline for RL. Sonographic diagnosis of the large for gestational age the performance of obstetrical ultrasound. In: ACR practice fetus at term: does it make a difference? Obstet Gynecol Jan, guidelines and technical standards, 2007. Reston (VA): ACR; 1992;79(1):55-8. (Level III) 2007. p. 1025-1033. (Level III) 21. Parry S, Severs CP, Sehdev HM, Macones GA, White LM, 4. Ultrasonography in Pregnancy. ACOG Practice Bulletin No. Morgan MA: Ultrasonographic prediction of fetal macroso- 101. American College of Obstetricians and Gynecologists. mia. Association with cesarean delivery. J Reprod Med Jan, Obstet Gynecol 2009;113: 451–61. (Level III) 2000;45(1):17-22. (Level II-2) 5. Hahn RG, Roi LD, Ornstein SM, et.al. Obsetric Ultrasound 22. Blackwell SC, Refuerzo J, Chadha R, et al. Overestimation Training for Family Physicians, Results from a Multi-Site Study. of fetal weight by ultrasound: does it influence the likelihood Jour Fam Pract 1988;26(5)553-558. (Level II) of cesarean delivery for labor arrest? Am J Obstet Gynecol 6. Smith CB, Sakornbut EL, Dickinson LC, Bullock GL. 2009;200:340.e1-340.e3. Quantification of Training in Obstetrical Ultrasound: A Study of 23. Weeks JW, Pitman T, Spinnato JA 2nd: Fetal macrosomia; Family Practice Residents J Clin Ultrasound 1991;19:479-483. does antenatal prediction affect delivery route and birth (Level III) outcome? Am J Obstet Gynecol Oct, 1995;173(4):1215-9. 7. Rodney WM, Deutchman ME, Harman KJ, Hahn RG. Obstetric (Level II-2) Ultrasound by Family Physicians. J Fam Pract 1992;34:186- 24. Boulvain M, Stan CM, Irion O. Elective delivery in diabetic 200. (Level III) pregnant women. Cochrane Database of Systematic Reviews 8. Nabhan AF, Abdelmoula YA. Amniotic fluid index versus single 2001, Issue 2. Art. No.: CD001997. DOI: 10.1002/14651858. deepest vertical pocket: a meta-analysis of randomized control CD001997. (Level 1) trials. Int J Gynaecol Obstet 2008; 104:184–188. (Level II) 25. Berghella V, Bega G, Tolosa JE. Berghella M. Ultrasound 9. Manning FA, Platt LD, Sipos L. Antepartum fetal evaluation: assessment of the cervix. Clinical Obstetrics and Gynecology development of a fetal biophysical profile score. Am J Obstet 2003;46:947-62. (Level III) Gynecol 1980; 136:787. (Level II) 26. Grimes-Dennis J, Berghella V. Cervical length and predic- 10. Manning FA, Antepartum fetal testing: a critical appraisal. tion of preterm birth. Current Opinion in Obstetrics and Current Opinion in Obstetrics and Gynecology 2009, 21:348– Gynecology 2007;19:191-5. (Level III) 352 (Level III) 28. Berghella V, Roman A, Daskalakis C, et al. Gestational age at 11. Electronic fetal heart rate monitoring: research guidelines for cervical length measurement and incidence of preterm birth. interpretation. National Institute of Child Health and Human Obstetrics and Gynecology 2007;110:311-7. (Level III) Development Research Planning Workshop. Am J Obstet 29. Berghella V, Baxter JK, Hendrix NW. Cervical assessment Gynecol. 1997;177:1385–1390 (Level III) by ultrasound for preventing preterm delivery. Cochrane 12. Miller DA, Rabello YA, Paul RH. The modified biophysical pro- Database of Systematic Reviews 2009, Issue 3. Art. file: Antepartum testing in the 1990s AM J OBSTET GYNECOL No.:CD007235. DOL:10.1002/14651858. CD007235. pub2. First 1996;174:812-7 (Level III) version published on line: 8 July 2009. Level I 13. Kim SY, Khandelwal M, Ganghan JP, et al. Is the intrapartum 30. Ness A, Visintine J, Ricci E, Berghella V. Does knowledge biophysical profile useful? Obstet Gynecol 2003;102:471-6 of cervical length and fetal fibronectin affect management (Level III) of women with threatened preterm labor? A randomized trial. American Journal of Obstetrics and Gynecology 14. Alfirevic Z, Stampalija T, Gyte GML. Fetal and umbilical 2007;197(4):426.e1-426.e7. (Level II) Doppler ultrasound in high-risk pregnancies. Cochrane Database of Systematic Reviews 2010, Issue 1. Art. No.: 31. Fox, Nathan S.; Silverstein, Michael; Bender, Samuel; Klauser, CD007529. DOI: 10.1002/14651858.CD007529.pub2. (Level I) Chad K.; Saltzman, Daniel H.; Rebarber, Andrei Active Second-Stage Management in Twin Pregnancies Undergoing 15. Eik-Nes SH, Salvesen KA, Okland O, Vatten LJ. Routine ultra- Planned Vaginal Delivery in a U.S. Population Obstetrics & sound fetal examination in pregnancy: the “Alesund” random- Gynecology. 115(2, Part 1):229-233, February 2010. (Level II) ized, controlled trial. Ultrasound Obstet Gynecol 2000;15:473- 8. (Level I). 32. Whitworth M, Bricker L, Neilson JP, Dowswell T. Ultrasound for fetal assessment in early pregnancy. Cochrane Database of 16. Delpapa EH, Mueller-Heubach E: Pregnancy outcome follow- Systematic Reviews 2010, Issue 4. Art. No.: CD007058. DOI: ing ultrasound diagnosis of macrosomia. Obstet Gynecol Sep, 10.1002/14651858.CD007058.pub2 (Level I) 1991;78 (3Pt1):340-3. (Level III)

— Chapter O: Diagnostic Ultrasound in Labor and Delivery — 17 33. Gülmezoglu AM, Crowther CA, Middleton P. Induction of labour for improving birth outcomes for women at or beyond term. Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD004945. DOI: 10.1002/14651858.CD004945.pub2. (Level I) 34. Bricker L, Neilson JP, Dowswell T. Routine ultrasound in late pregnancy (after 24 weeks’ gestation). Cochrane Database of Systematic Reviews 2008, Issue 4. Art. No.: CD001451. DOI: 10.1002/14651858.CD001451.pub3. (Level I) 35. AAFP Ultrasounography, Diagnostic in OB/GYN (Position paper). Training and Credentialing of Family Physicians in Diagnostic Ultrasonography (Level III) http://www.aafp.org/ online/en/home/policy/policies/u/ultrasonography 36. ACOG Committee on Ethics. Committee Opinion. Nonmedical Use of Obstetric Ultrasonography. August 2204, Number 297. (Level III)

18 — — Chapter O: Diagnostic Ultrasound in Labor and Delivery APPENDIX 1 DOCUMENTATION OF LABOR AND DELIVERY ULTRASOUND SCAN

Patient name:______Date:______Patient I.D. number:______Attending physician:______Other physician:______Pregnancy data: Maternal age:______G:______P:______Ab:______Today’s gestational age:______weeks + or - ______weeks. Based on: LMP of:______and/or previous ultrasound scan on: ______(date) Findings of today’s fetal heart rate tracing: ______

Reason for L&D ultrasound scan: (check all that apply) q No prenatal care / unknown dates q PROM q Pain q Part of antepartum testing (amniotic fluid index) q Bleeding q Trauma q Adjunct to amniocentesis q Suspected breech presentation q Preterm labor q Adjunct to external version q Preterm labor q ______q Fetal weight estimate (reason: ______) Other coexisting problems: ______Findings: (complete only relevant items) (attach photos to reverse side or new page) Fetal heartbeat: q yes q no Fetal number: ______Fetal lie, presentation and position:______Placental location:______Biophysical data: Amniotic fluid index: ______+ ______+ ______+ ______= ______cm. Or largest vertical pocket: _____cm Breathing: q yes q no Tone: q yes q no Body movement: q yes q no Biophysical score: ______points out of possible ______points. Fetal biometry: BPD = ______cm = ______weeks + or - ______weeks Femur = ______cm = ______weeks + or - ______weeks Head Circ. = ______= ______weeks + or - ______weeks Abd. Circ. = ______cm = ______weeks + or - ______weeks Composite gestational age = ______weeks + or - ______weeks. EDD: ______+ or - ______weeks. Estimated fetal weight: ______grams. Describe any abnormalities seen: ______Consultative scan ordered: q yes q no Diagnosis related to reason for scan: ______Plan of treatment: ______

Signature(s): ______Date and time ______

Form L&DUSRPT.DOC Deutchman 7/1995

— Chapter O: Diagnostic Ultrasound in Labor and Delivery — 19 Chapter P Neonatal Resuscitation slide 1 Karen Ailsworth, MD, MS, FAAP

Revised July 2013

OBJECTIVES slide 2 After completing this chapter, participants will be able to: 1. Select and properly assemble the equipment needed for neonatal resuscitation. 2. Describe how to perform a rapid initial evaluation of the newborn. 3. Describe subsequent resuscitation steps for a depressed newborn (ventilation, chest compression and drugs) and their application. 4. Describe actions to take when meconium is present.

OVERVIEW This chapter provides an overview of the basic techniques used in neonatal resuscitation. These guidelines are applicable to the newly born as well as for infants who require resuscitation within the first few months after birth. An accompanying workshop will cover the techniques of airway management, positive-pressure (bag and mask) ventilation, endotracheal intubation, and protocols for dealing with meconium. The information presented is consistent with guidelines established by the American Academy of Pediatrics and the American Heart Association in the 2011 6th edition Neonatal Resuscitation ProgramTM (NRPTM ).1,2 The ALSO® program is not intended to substitute for the advanced training and formal certification in neonatal resuscitation provided by the NRPTM.

One of the most satisfying events in medicine is being present at the birth of a healthy baby. Fortunately, more than 90 percent of infants have an uneventful birth, and can immediately be given to their mother. About one in ten infants have some difficulty with the transition to extrauterine life. More than half of distressed infants have identifiable risk factors; however since many do not, it is imperative to be prepared for the resuscitation of a distressed infant at every delivery. Although resuscitating a depressed newborn may seem an intimidating task, the maternity care provider can take comfort in the knowledge that infants generally respond well to simple, non-pharmacological measures and that mastery of a few simple techniques will allow the resuscitator to deal effectively with all but the most severely depressed infants. Less than one percent of infants requiring resuscitation will require medications.

The transition from intrauterine to extrauterine life depends upon a physiologically complicated series of events which are driven by changes in oxygen pressure and the ability of the infant to take its first breaths effectively. If the infant has its airway blocked by mucus or meconium, or has poorly compliant lungs because of immaturity or meconium, oxygenation and ventilation may not be effective. Therefore, obtaining an airway and assisting with breathing remain the mainstays of infant resuscitation.1,2 This is in contrast to recent changes in adult and pediatric resuscitation protocols where the “C” of the “A-B-C” (Airway-Breathing-Circulation) has been given priority.

— Chapter P: Neonatal Resuscitation — 1

PATHOPHYSIOLOGY Neonatal depression is most often caused by either hypoxemia or by drugs administered to the mother. The unborn infant can tolerate a degree of hypoxemia and acidosis that would be detrimental to a child or an adult, but if the hypoxemia is severe enough, a predictable sequence of events will ensue. An infant subjected to hypoxemic stress will initially go through a brief period of rapid breathing, after which it will stop breathing. This is known as primary apnea. During primary apnea, the heart slide 3 rate and neuromuscular tone decrease. If the infant is delivered during this stage, it will generally respond well to stimulation and supplemental oxygen. However, if the hypoxemic stress continues, the slide 4 infant’s condition will deteriorate steadily. The infant goes through a phase of deep, irregular gasping, after which it will again stop breathing. This is known as secondary apnea. During secondary apnea, the infant’s heart rate, blood pressure, and PaO2 will fall profoundly.

An infant delivered in secondary apnea will not resume breathing spontaneously, nor will it respond to stimulation and supplemental oxygen. This infant must have assisted ventilation to correct the hypoxemia, or it will deteriorate further and die. The hypoxemic infant may progress through primary apnea into secondary apnea in utero. Since the two phases of apnea are clinically indistinguishable from each other, any infant born apneic must be presumed to be in secondary apnea.1,2 This does not mean the maternity care provider should not attempt stimulation of the infant, but that he or she should try only one or two attempts at stimulation before progressing to more aggressive intervention. For an infant in secondary apnea, any delay in treatment will lead to a much longer delay in establishing effective spontaneous respirations, or even death.

There are two features of the fetal cardiopulmonary system that may cause problems for a depressed infant in its attempts to establish extrauterine life. First, the infant’s lungs are filled with fluid in utero. slide 5 To expand the alveoli and clear this fluid, the first few breaths require more pressure than subsequent breaths. Therefore, an infant who is making only weak respiratory efforts will not be able to move air into its lungs and will become increasingly hypoxic and acidotic without intervention. Second, at birth, relatively little blood flows through the pulmonary vascular bed, as most is shunted around the lungs slide 6 through the ductus arteriosus. Normally, as the infant begins to breathe, the increasing concentration of oxygen in the blood causes the ductus to constrict and the pulmonary arterioles to dilate. In the hypoxemic infant the ductus remains open, allowing oxygenated blood to bypass the lungs, and this persistent fetal circulation further impairs adequate oxygenation. If the infant is mildly to moderately hypoxemic, positive pressure ventilation via bag and mask will be sufficient to establish normal newborn circulation. However, if the infant is severely hypoxemic, cardiac compressions or medications become necessary. It should be emphasized that the vast majority of depressed newborns will respond to effective ventilation; few will need compressions, and even fewer, medications. Thus, it is time well spent learning the basics of neonatal oxygenation and ventilation.

GETTING READY FOR RESUSCITATION One of the most important steps in neonatal resuscitation is preparation. Frequently the prenatal or perinatal history will reveal risk factors that may indicate a need for resuscitation. (See Appendix A.) slides 7, 8 Since the need for resuscitation cannot be predicted with 100 percent certainty, appropriate personnel and equipment should be ready at every delivery.

2 — — Chapter P: Neonatal Resuscitation Personnel Needed for Neonatal Resuscitation There should be one person trained to resuscitate newborns present in the delivery room for each baby to be delivered. This person should not have any other duties after the infant is born. If there is more than one baby, there needs to be at least one resuscitator per baby at the delivery (not on call in another part of the hospital or at home).

Equipment Needed for Neonatal Resuscitation Wherever newborn infants are cared for, appropriate resuscitation equipment should be immediately available and in working order. The maternity care provider must be familiar with the location and operation of all the equipment necessary for neonatal resuscitation, especially since infant workstations may be set up differently in various labor and delivery units. Since the need for resuscitation cannot be predicted, the minimum required setup is a radiant heater, turned on before delivery, and towels or blankets for drying the newborn. It may be helpful to have drug doses and other “cheat sheets” posted on or near the radiant heater for quick reference.

The maternity care provider should ensure that oxygen lines are connected and able to deliver a flow of five liters per minute. The resuscitation bag and mask unit should work properly and have appropriately sized masks. Suction lines should be connected and adjusted to keep occluded suction between 80 to 100 mm Hg. The laryngoscope should have appropriately sized blades (Blade size No. 1 for term newborns and No. 0 for preterm infants) and a properly functioning light. Please see Appendix B for complete list. If conditions suggest that the delivery of a depressed infant is likely, all equipment should be set up in advance.

INITIAL STABILIZATION AND EVALUATION OF THE NEWBORN slide 9 Resuscitation always begins with a rapid evaluation of the newborn. Evaluation begins with determining if the infant is term, breathing or crying, and has normal tone.1,2 Apgar scores are not useful indicators of the need for resuscitation. Resuscitation of a depressed newborn must begin within 30 seconds, well before the one-minute Apgar score is calculated.

Rapid Evaluation of the Newborn Resuscitation is a rapid series of specific steps carried out in response to the newborn’s clinical condition (See Figure 1). All newly born infants should be dried, provided warmth, and, if obstructed, have their airway suctioned. Stimulation is provided if needed. The term infant, born breathing or crying, and with good tone, can remain with their mother while these steps are carried out. The meconium stained infant, if vigorous, can also stay with its mother for the initial steps. Care of the depressed meconium stained infant will be covered in a later section.

— Chapter P: Neonatal Resuscitation — 3

Research supports delayed cord clamping (one to three minutes after delivery with the infant at or below the level of the placenta) for preterm infants.3,4,5 There are many benefits, including significant decreases in intraventricular hemorrhage5 and anemia.7 Evidence is not as strong for term infants in high resource settings and research is ongoing,3,4 however delayed cord clamping is a reasonable option for term infants and these infants can then be placed skin to skin on the mother’s chest.3,4,7

Figure 1. Rapid Evaluation of the Newborn slide 10

Initial steps: • Warm, dry, stimulate, position • Clear airway

Breathing, HR > 100, • Evaluate respirations no cyanosis • Heart rate (HR) Observational care • Color

HR > 100 but labored breathing or persistent cyanosis

• Clear airway Apneic, gasping or HR < 100 • Spo2 monitoring • Consider CPAP

• Positive-pressure ventilation Post-resuscitation care • Spo2 monitoring Effective ventilation, HR > 100

HR < 60 HR > 60

• Consider intubation • Chest compressions • Coordinate with PPV

4 — — Chapter P: Neonatal Resuscitation ASSESSMENT Ongoing assessment is also necessary for all newborns. Assessment consists of evaluating three signs: heart rate, respirations, and oxygenation. Increasing heart rate is the most sensitive indicator of effective resuscitation. Heart rate can be determined by auscultation (preferred method), or by palpation of the pulses at the umbilical stump (preferred site) or femoral or brachial arteries.1,2 Oxygenation can be assessed with an oximeter. An oximeter is more reliable than judging the level of cyanosis. Oximetry is recommended once positive pressure ventilation is given beyond a few breaths, if supplemental oxygen is given, or for persistent cyanosis. The oximeter should be placed on the right (pre-ductal) wrist or palm. Numerous studies8,9,10 have established the predictable

SpO2 of healthy, term newborns within the first ten minutes of life (see Figure 2). These apply for both vaginal and cesarean deliveries. At altitudes above 4000 m, SpO2 will be slightly lower and take longer to optimize.11

1,2 Figure 2. Targeted Pre-ductal SpO2 After Birth All three signs, heart rate, respirations, Target Spo2 Right Arm and oxygenation, should be assessed 1 min 60-65 percent every 30 seconds initially, and then 2 min 65-70 percent 3 min 70-75 percent continuously with prolonged resuscitation. 4 min 75-80 percent 5 min 80-85 percent 10 min 85-95 percent

CLEARING THE AIRWAY slide 11 If the infant is preterm, or not breathing or crying, or has poor muscle tone, initial resuscitation steps are taken. The first step is to ensure the infant’s airway is open by positioning the infant properly. The proper airway position is with the neck slightly extended, the “sniffing” position, since both underextension and hyperextension of the neck will obstruct the airway. Deep suction, even with a bulb syringe, should be avoided in healthy, vigorous newborns12, 13 unless there is suspicion of airway obstruction, as it may cause or aggravate bradycardia through vagal-mediated reflexes. When needed, suction the mouth first, and then the nose. (Suctioning the infant to remove meconium is the one condition where this rule does not apply. This will be covered in the section on meconium.)

If there are no effective, spontaneous respirations after the infant has been dried and airway patency ensured, stimulation by slapping the soles of the feet or rubbing the infant’s back may be necessary. Either form of stimulation should be attempted only once or twice before positive pressure ventilation (PPV) is begun.

TEMPERATURE CONTROL During resuscitation of a depressed newborn, normothermia is the goal. A cold environment places stress on the newborn’s circulatory system during adaptation to extrauterine life, and careful drying can minimize this. Drying the baby also provides stimulation and may be enough to initiate spontaneous respirations in cases of mild depression. Very low birth-weight (VLBW) infants may require additional methods to maintain body temperature, including wrapping in plastic14 and additional heat sources such as heated saline bottles, a radiant heater, or a heated mattress.15 VLBW babies should be wrapped in plastic as soon as possible after birth, before drying, to prevent as much heat loss as possible. However their temperature should be monitored to avoid overheating; the goal axillary temperature is 36.5° Celsius.2

— Chapter P: Neonatal Resuscitation — 5

Hyperthermia should be avoided, as it may worsen the extent of brain injury following hypoxemia-ischemia. There is also evidence that hypothermia can prevent brain damage.16,17,18,19 Therapeutic hypothermia may be an option for some term and late preterm infants with hypoxic-ischemic encephalopathy, within hours of resuscitation, under the auspices of a tertiary care center providing this service.

OXYGEN Supplemental oxygen administration to newborns can be beneficial but also has risks. Lack of oxygen can cause tissue damage or death, and a poorly oxygenated heart is less effective. Oxygen toxicity may occur as fetuses and newborns are well adapted to oxygen levels below 95 to one hundred percent and can sustain tissue and organ damage if SpO2 levels are maintained at high levels for more than a few minutes. Premature infants are even more susceptible to oxygen toxicity. The 2011 Neonatal Resuscitation Program Guidelines recommend room air for PPV of term newborns.

For preterm infants, oxygen should be blended until the SpO2 appropriate for the infant’s age in minutes is reached (See Figure 2).19,20,21 One hundred percent oxygen should be used if chest compressions or medications are needed. Furthermore, an oximeter probe should be applied to the newborn’s right (preductal) hand if PPV is initiated.1,2

Flow rates higher than 5 liters per minute do not improve oxygen delivery and subject the infant to thermal stress from the stream of cold air. The mask end of a self-inflating bag should not be used to administer oxygen, since a flow rate of five liters per minute is often insufficient to open the valves in the bag and move the oxygen through to the baby.

POSITIVE-PRESSURE VENTILATION (PPV, BAG AND MASK VENTILATION) Positive pressure ventilation (PPV) is the mainstay of ventilatory support for the depressed newborn. slide 12 It has the advantages of being immediately available, of requiring less operator skill than endotracheal intubation, and of having less potential for injury to the infant. If necessary, PPV can be performed effectively for long periods of time. PPV does require more than one individual to be present to assist with resuscitation.1,2

The infant is positioned with the neck slightly extended to ensure airway patency. A small cloth roll under the infant’s shoulders can help to maintain the “sniffing” position and prevent obstruction of the airway by inadvertent flexion of the infant’s neck.

The resuscitator should select a mask that covers the infant’s nose and mouth, just to the tip of the slide 13 chin. Too small a mask will not provide a good seal. Too large a mask can prevent a good seal, or put pressure on the infant’s eyes, causing a vagal response. The easiest bags to use are the self- inflating models. However, the resuscitator should become skilled at using whatever equipment is in use at his or her hospital.

Before beginning ventilation, the resuscitator should ensure the bag moves air through the mask slide 14 when compressed, oxygen is flowing through the system, and the oxygen flow rate is set at 5 liters per minute. Anesthesia bags produce this concentration automatically, while self-inflating bags must have a reservoir attached to do this. A safety feature that all systems should have is a means for controlling the amount of pressure generated during ventilation. Anesthesia bags normally have a pressure gauge attached, while most self-inflating bags have a pop-off valve that releases at a pressure of 30 to 40 cm H2O.

6 — — Chapter P: Neonatal Resuscitation When ventilating an infant, most physicians find it easiest to use the non-dominant hand to hold the mask on the infant’s face and the dominant hand to compress the bag. Usually, the resuscitator stands at the infant’s head, but other positions are acceptable, as long as there is a clear view of the infant’s chest. The resuscitator can use the hand that holds the mask to maintain and adjust the seal on the infant’s face and to control the position of the infant’s head to maintain and adjust the airway. The bag should be compressed with the fingertips only, rather than the entire hand. The tidal volume of a term infant’s lungs is only about 20 to 30 cc, so full ventilation can be accomplished with minimal compression of the bag. It is now recommended that initial breaths be given at

20 cm H2O. Success can be documented by noting rising heart rate, rising oxygen saturation and 2 audible breath sounds bilaterally. increasing pressure to 30 to 40 cm H2O is sometimes necessary.

Ventilation should be performed at a rate of 40 to 60 breaths per minute. Every 30 seconds, the assistant should report heart rate and breath sounds, assessing heart rate first. Increasing heart rate is the primary sign of effective ventilation; other signs are improving color, spontaneous breathing, and improving muscle tone.1,2 When spontaneous respirations are present and the heart rate is greater than 100, positive pressure ventilation may be gradually reduced and discontinued.2 During or after prolonged PPV it may be necessary to insert an oro- or nasogastric tube (8F feeding tube), vented to air, to relieve any gastric distention caused by bagging.

ENDOTRACHEAL INTUBATION Endotracheal intubation is required for suctioning the trachea in the case of meconium-stained slide 15 amniotic fluid in a depressed infant. Other indications are to provide prolonged ventilation, to ventilate an infant in whom positive-pressure ventilation has been ineffective, and to ventilate an infant suspected of having a diaphragmatic hernia. Two people are needed—one to intubate and ventilate, and one to assist in managing equipment.

The infant should be positioned in the same “sniffing” position as for positive-pressure ventilation. slide 16 The laryngoscope is held in the left hand, using the thumb and fingertips rather than the closed fist, to avoid using excessive force that could injure the infant.

The laryngoscope blade is introduced into the vallecula, between the anterior wall of the hypo- slide 17 pharynx and the epiglottis. The blade is introduced along the midline of the tongue until the tip is approximately in position. Some providers prefer to introduce the blade along the right side of the tongue and sweep it to the midline when the tip is at the base of the tongue. This is an acceptable alternative technique. The laryngoscope is then lifted until the vocal cords are visualized. Care should be taken not to rock the blade back on the upper alveolar ridge. Final correction of blade placement can then be made and the tube inserted.

The appropriately sized endotracheal tube is chosen based on estimated fetal weight and gestational age. Endotracheal tubes for neonates should be uncuffed. Insert the tube until the tip lies 1 to slide 18 2 cm beyond the vocal cords. Many tubes have markings to indicate the appropriate placement.

A stylet stiffens the tube and may facilitate intubation. If used, the stylet should be completely covered within the endotracheal tube to prevent injury to the infant’s airway and removed once the endotracheal tube passes the vocal cords. Once the tube is in place, either suction or the ventilation bag is attached. If the tube is used for ventilation, its position should be confirmed by noting 22 improvement in heart rate or with a carbon dioxide (CO2) detector (preferred methods). Watching

— Chapter P: Neonatal Resuscitation — 7 the tube enter the trachea between the vocal cords, observing symmetrical chest wall motion, listening to both sides of the chest above the nipple line for equal breath sounds, and watching for mist in the endotracheal tube may also be helpful, but have not been studied systematically.1,2 The tube should then be taped securely in place and an x-ray obtained for final confirmation of the tube position.

MECONIUM Meconium stained amniotic fluid (MSAF) is a common complication of labor and delivery. Aspiration of meconium into the lungs can be associated with serious and even fatal pulmonary compromise. Many cases of meconium aspiration occur in utero and are not preventable. slide 19

Endotracheal intubation to suction below the cords and remove meconium from the airway is indicated only for infants with MSAF and evidence of distress: absent or depressed respirations, heart rate less than 100 per minute, or poor muscle tone.1,2,23,24 A laryngoscope and endotracheal tube should be prepared, and the suction apparatus should be connected and tested, before delivery whenever possible. Wall suction should be used, with the suction adapter connected directly to the endotracheal tube.

Immediately following delivery, the depressed, meconium stained infant should be intubated as rapidly as possible, ideally before it has taken a breath. Suctioning is accomplished with the endotracheal tube, and the process is repeated until no meconium returns. If meconium is found below the cords, the infant should be watched carefully for any signs of respiratory distress, hypoxemia, or pneumonia from meconium aspiration.

When MSAF is detected before delivery, it can be helpful to warn the parents that, if the baby is “non-vigorous”, it will be quickly taken for intubation and will not be stimulated to cry until the airway is cleared.

CARDIAC COMPRESSIONS In the unusual event that the infant’s heart rate is less than 60 per minute after 30 seconds of effective ventilation, cardiac compressions will be necessary to support circulation until effective oxygenation and pulmonary blood flow is established.1,2 slide 20

Again, because oxygenation is necessary for perfusion of coronary muscle, effective ventilation should be ensured before starting chest compressions.

A second resuscitator will be necessary for chest compressions. The lower third of the sternum should be used for compression, being careful to avoid the xiphoid process. Acceptable techniques include having two thumbs on the sternum, superimposed or adjacent to each other, with fingers encircling the chest to support the back, or two fingers placed on the sternum at right angles to the chest with the other hand supporting the infant’s back. The “two thumbs” chest compression is the preferred technique in newly born infants, as it may offer some advantages in generating peak sys- 25,26 tolic and coronary perfusion pressures. The “two fingers” technique may be easier to perform slide 21 if there are many people close to the infant performing other resuscitative tasks. Compression to approximately one-third the depth of the chest is recommended.27 Three compressions are performed and a pause for ventilation left in place of the fourth compression. This gives an effective

8 — — Chapter P: Neonatal Resuscitation rate of 90 compressions and 30 ventilations per minute. The heart rate should be re-evaluated every 45 to 60 seconds while compressions are being performed. If the heart rate is less than 60 per minute after 45 to 60 seconds of chest compressions with effective ventilation, then drug therapy will be necessary.

MEDICATIONS Drugs are rarely used in neonatal resuscitation, but may be needed for the most critically depressed slide 22 newborns and those with significant anomalies. Since drugs are so rarely needed, a card listing the doses should be kept with the resuscitation supplies for quick reference. Note that all drug doses are calculated based on the infant’s weight. Since the weight is not precisely known, the physician must clinically estimate the baby’s size to calculate the doses. The endotracheal tube size chart can be used to estimate the baby’s weight, if the baby is appropriately sized for gestational age and the gestational age is known.

Intravenous (IV) access is the preferred route for administration of fluids and of some drugs. Three acceptable forms of IV access are umbilical catheterization, a peripheral IV, or intra-osseous. Resuscitators should use the method with which they are fastest and most comfortable. For many, quick and effective IV access can be secured with an umbilical venous catheter. It is important to not cut the cord too short if there is any chance it will be needed for IV access. To cannulate the umbilical vein, the umbilical cord is cut approximately two centimeters above the skin, and the stump is swabbed with antiseptic solution. The umbilical vein is easily identified as the largest of the three vessels, and is usually at the 11:00 to 12:00 position. A 3.5 mm or 5.0 mm umbilical venous catheter is inserted into the umbilical vein until blood is returned (this usually happens just below the abdominal wall). Do not insert the catheter beyond where blood can first be aspirated; medications can cause liver damage if the catheter is too close to the liver. The catheter is secured with umbilical tape to the abdomen and/or sutures to the umbilical stump. Umbilical catheterization should be done as quickly as possible and with sterile technique.

Epinephrine slide 23 The primary medication used in neonatal resuscitation is epinephrine. It is given if the infant’s heart rate is less than 60 per minute after 45 to 60 seconds of cardiac compressions combined with effective ventilation. Epinephrine acts as a positive inotropic and positive chronotropic agent, thereby improving systemic and pulmonary perfusion. The recommended dose is 0.1 to 0.3 ml/kg 1,2,28,29 of 1:10,000 concentration (0.01 to 0.03 mg/kg), and the intravenous route is preferred. When epinephrine is given through an IV catheter, it should be followed with a 0.5 to 1 mL flush of normal saline.2 The endotracheal (ET) route may be considered while IV access is being obtained, but safety and efficacy data are lacking for this practice.28 The ET dose is higher, up to 0.5 to 1 ml/kg of 1:10,000 concentration (0.05 to 0.1 mg/kg). Do not give the higher dose IV, as it has been associated with hypertension and brain and heart damage.2 Epinephrine may be repeated every five minutes as needed. Chest compressions and ventilation should be continued, and the heart rate should be re-evaluated every 45 to 60 seconds.

— Chapter P: Neonatal Resuscitation — 9

Volume Expanders Volume expanders are reserved for situations in which blood loss has occurred or the infant is clini- slide 24 cally hypovolemic.2 Using volume expanders in the absence of hypovolemia can cause fluid overload once effective circulation is established. Isotonic crystalloid solutions, such as normal saline or Ringer’s lactate, are the volume expanders of choice.29,30 O negative blood may be necessary to correct severe fetal anemia. The dose of volume expanders is 10 ml/kg intravenously, given slowly over five to ten minutes to avoid intraventricular hemorrhage.

Naloxone It is no longer recommended to give naloxone (Narcan) as an initial step of neonatal resuscita- slide 25 tion for newborns with respiratory depression.2,31 The first treatment for respiratory depression is PPV even when women have received narcotics less than four hours prior to delivery. If respiratory depression persists, naloxone can be considered. Avoid giving naloxone to an infant whose mother has a history of narcotic dependence as naloxone can cause withdrawal seizures in this situation.

NON-INITIATION AND DISCONTINUATION OF RESUSCITATION Ethical considerations may cause a provider to contemplate non-initiation of resuscitation in slide 26 extremely premature infants and infants with severe congenital abnormalities.1,2 For infants with confirmed gestation less than 23 weeks or birth weight less than 400 grams.32 in cases of anencephaly, or confirmed lethal malformation or genetic disorder, for example, resuscitation is very unlikely to result in survival, and high morbidity is likely among the rare survivors. In such cases, non-initiation may be appropriate. Although there is no U.S. federal law requiring neonatal resuscitation under all circumstances, health care providers must be aware of the laws and regulations in their area, including which relatives have rights to make decisions for the baby.

In conditions with uncertain prognosis in which possibility of survival is questionable, the morbidity rate is relatively high, and the anticipated burden to the child is high, parental desires concerning initiation of resuscitation should be supported. This may include babies of 23 to 24 weeks gestation, at the borderline of survivability. Discontinuation of resuscitation may be justified if after ten minutes of complete and adequate resuscitative efforts, there is no heart beat and no respiratory effort.1,2,33,34 After ten minutes of asystole, resuscitation is very unlikely to result in survival, or survival without severe disability.

Ideally these conversations would take place before birth, with the understanding that management decisions may change after delivery, when more accurate information regarding gestational age and the baby’s condition may be available.

NEONATAL TRANSPORT Occasionally a newborn will require care that is beyond the resources of the hospital where the slide 27 birth occurs due to prematurity or neonatal morbidity. When the need for a higher level of care is anticipated prior to delivery and circumstances allow, it is best to arrange a maternal transport prior to birth as neonatal outcomes are improved when delivery of preterm infants occurs in facilities with Level III neonatal intensive care.35,36

10 — — Chapter P: Neonatal Resuscitation slide 28 When high-risk neonatal transport is needed, a neonatal transport team with advanced newborn resuscitation skills should be sent if possible. Temperature control is important and infants under 29 weeks gestational age or weighing less than 1 kg should be wrapped in food grade polyethylene plastic bag.2 slide 29 Monitor the baby’s temperature when a plastic bag is used as overheating can occur; the ideal axillary body temperature is 97.7 degrees Fahrenheit. Infants born at > 36 weeks gestational age who have a hypoxic-ischemic encephalopathy and receive therapeutic hypothermia within six hours of birth have decreased risk of mortality and disability16 among survivors. Care coordination with transport to a tertiary care center is indicated to discuss temperature goals during transport.

SUMMARY slide 30 Although a minority of newborns require resuscitation, preparation and practice are critically important. Many of the infants needing resuscitation do not have identifiable risk factors that permit prediction of the need for resuscitation prior to the delivery. Positive pressure ventilation is sufficient for the majority of infants needing resuscitation. Oximetry, when available, can guide oxygen administration during resuscitation and avoid toxicity from excessive oxygen. Chest compression and medicines are needed in a minority of resuscitations. Epinephrine is best administered intravenously and naloxone should only be given to babies with recent but not chronic narcotic exposure with respiratory depression unresponsive to PPV. Intubation to clear the airway of meconium is only indicated for nonvigorous newborns.

GLOBAL PERSPECTIVES: NEONATAL RESUSCITATION Four million of the 130 million babies born worldwide die within the first four weeks of life each.37 A child in a developing country is 14 times more likely to die in the first month of life than a child born in a developed country38 and 99 percent of the neonatal deaths are in low and middle-income nations.39 At least one million of these deaths (75 percent) occur in the first 24 hours and many may be preventable through training in the basics of neonatal resuscitation: keeping the newborn dry and warm, providing appropriate stimulation, clearing the airway, and providing bag mask ventilation when needed. The American Academy of Pediatrics has developed a course, Helping Babies Breathe (HBB) (http://www.helpingbabiesbreathe.org/), which teaches neonatal resuscitation in a manner more appropriate for low-resource settings. A study in Tanzania found that training in HBB lead to a significant reduction in neonatal deaths. Additional details regarding neonatal resuscitation in developing countries can be found in the Neonatal Resuscitation Chapter Addendum of the Global ALSO® Manual by visiting https://nf.aafp.org/shop and selecting the ALSO link.

— Chapter P: Neonatal Resuscitation — 11

SUMMARY TABLE OF CHANGES IN NRP PROTOCOLS FROM 2008 TO 20111,2

2008 Recommendations 2011 Recommendation

Use of oxygen *Use 100 percent O2 if baby is cyanotic or needs PPV. *Use room air if baby is cyanotic or needs PPV. during *Use room air, if 100 percent O unavailable. *If baby is < 32 weeks Resuscitation 2 -titrate O2 concentration to achieve targeted pre-ductal SpO2 using oxygen *If baby is < 32 weeks blender and oximeter. - titrate O2 concentration to achieve oxyhemoglobin concentration of 90 to 95 percent using oxygen *Use 100 percent O2 if chest compressions or medications given, and titrate blender and oximeter. to targeted pre-ductal SpO2 - Use 100 percent O if HR does not respond rapidly. 2 *Apply oximeter to right wrist or hand (pre-ductal) to confirm cyanosis or if *Visually assess color of infant. prolonged PPV given.

Meconium *Intrapartum suctioning no longer recommended. *No change. *Intubate and suction only meconium stained infants who are depressed.

Bag-and-mask *Call for assistance when beginning PPV Same as in 2008 PLUS: ventilation *Ask for assistant to report heart rate, then breath *Emphasis on effective PPV as means to resuscitate the majority of neonates. sounds as signs of adequate ventilation. *Encourage troubleshooting of PPV with Mnemonic MR SOPA2: *Increasing heart rate is the primary indicator of M=Mask adjustment effective ventilation; others are spontaneous breath- R=Reposition airway ing, and improving color and tone. S=Suction mouth and nose O=Open mouth P=Pressure (of PPV) increase A=Airway alternative: endotracheal tube (ETT) or laryngeal mask airway (LMA) *Assess color with oximeter placed pre-ductally

Devices for *Self-inflating and flow-inflating bag-and-mask, *Same assisting endotracheal intubation. *Consider T-piece resuscitators, especially in premature infants39,40,41,42 ventilation8 *CPAP may be helpful41 *Consider LMA 41,42,43,,44 in infants who have failed PPV or intubation.

Endotracheal *Check placement of ETT with stethoscope over *CO2 detection with colorimetric CO2 detector is preferred method. Also intubation lungs and abdomen. may check for increasing heart rate.

Medications *Epinephrine route: IV, ETT, IM *IV (umbilical vein) is preferred. Consider ETT while obtaining IV access. May also use intraosseous line.

Epinephrine dose Epinephrine dose: *IV: 0.1 to 0.3 ml/kg of 1:10,000 solution, drawn up in a 1-ml syringe. *ETT: 0.5 to 1.0 ml/kg of 1:10,000 solution, drawn up in a 3-ml or 5-ml syringe.

Naloxone *No longer recommended as a primary medication. *Restore heart rate and color by supporting ventilation before giving naloxone. *Routes: IV (preferred) or IM.

Temperature There is insufficient evidence to support hyper- or *Euthermia still the goal. control hypothermia; the goal should be to achieve euthermia *Prevent heat loss via evaporation in premature infants by wrapping in during resuscitation. polyethylene from the neck down, immediately after birth, before drying. *Hypothermia under the auspices of a tertiary care center within hours of birth may improve outcomes in infants affected by hypoxic-ischemic encephalopathy.

Withholding or *Consider withholding efforts when gestation, birth *Same as before EXCEPT may discontinue after ten minutes of continuous, discontinuing weight, or congenital anomalies are almost certain to effective ventilation without signs of life. resuscitative result in early death or unacceptably high morbidity. *Non-initiation and discontinuation of resuscitation are considered ethically efforts *Consider discontinuing efforts if no signs of life after equivalent. 15 minutes of continuous, effective ventilation. *Parents views on starting resuscitation should be supported in conditions with uncertain prognosis, where there is a high rate of morbidity and borderline survival, and where the burden to the child is high.

Teamwork *Not addressed *Teamwork and good communication result in better outcomes during emergency situations. These are skills that can be learned.44,45,46,47

Chest *Allow 30 seconds of chest compressions before *Two thumb encircling technique preferred. Compressions reassessing *Allow 45 to 60 seconds of chest compressions before reassessing.

— Chapter P: Neonatal Resuscitation — 12

APPENDICES Appendix A: Risk factors for neonatal resuscitation Maternal – Bleeding in second or third trimester – Pregnancy induced hypertension or preeclampsia – Chronic hypertension – Substance abuse – Drug therapy (e.g. lithium, magnesium, adrenergic blocking agents, narcotics) – Diabetes mellitus – Chronic illness (e.g. renal, thyroid, cardiac, pulmonary, or neurologic disease) – Maternal pyrexia – Maternal infection – Premature rupture of membranes – Chorioamnionitis – Heavy sedation – Previous fetal or neonatal death – Mother > 35 years old – No prenatal care Fetal – Multiple gestation (e.g. twins, triplets) – Preterm gestation (especially less than 35 weeks) – Post term gestation (greater than 41 weeks) – Size/dates discrepancy – Alloimmune hemolytic disease – Polyhydramnios and oligohydramnios – Reduced fetal movement before onset of labor – Congenital abnormalities which may affect breathing, cardiovascular function or other aspects of perinatal transition – Intrauterine infection – Hydrops fetalis

Intrapartum – Prolonged rupture of membranes (greater than 18 hours) – Non reassuring fetal heart rate patterns – Abnormal presentation – Prolapsed cord – Prolonged labor (> 18 hours) – Precipitate labor – Antepartum hemorrhage (e.g. abruption, placenta previa, vasa previa) – Meconium in the amniotic fluid – Narcotic administration to mother within four hours of birth – Forceps or vacuum-assisted birth – Maternal general anesthesia – Emergency cesarean delivery – Breech or other abnormal presentation

— Chapter P: Neonatal Resuscitation — 13

Appendix B: Equipment Needed for Neonatal Resuscitation Adapted from Neonatal Resuscitation Program 6th edition 2011

Standard kits Breathing support – Prior preparation of standardized kits contain- – Face masks (range of sizes suitable for ing equipment for procedures (e.g. umbilical premature and term neonates) catheterization) can save considerable time in – Positive pressure ventilation device either: emergencies • T-Piece resuscitation device, or • Flow-inflating bag with pressure safety valve General and manometer, or – Firm but padded resuscitation surface • Self-inflating bag (240 mL) with a pressure – Overhead warmer release valve and a removable oxygen – Light for the area reservoir – Clock with timer in seconds – Medical gases to remain: – Warm blankets or towels • Source of oxygen (allowing flow rate of up to – Polyethylene bag or sheet, big enough for neo- 10 L/min) with flow meter and tubing nates less than 1500 g birth weight • Air/oxygen blender – Stethoscope (neonatal preferred) • Oximeter and probe – Pulse oximeter plus neonatal probe – Feeding tubes for gastric decompression (size 8F) and 20 ml syringe Airway management – Suction apparatus and suction catheters (sizes Circulation support 5F or 6F, 8F, 10F 12F or 14F) – Umbilical venous catheter (UVC) kit (including – Oropharyngeal airways (sizes 0,00 and 000) UVC sizes 3.5F and 5F) – Intubation equipment: – Peripheral IV cannulation kit • Laryngoscopes with neonatal blades (sizes – Skin preparation solution suitable for neonate 00, 0, 1 ) skin • Spare batteries and bulbs – Tapes/devices to secure UVC/IV cannula • Compatible laryngoscope handles and – Syringes and needles (assorted sizes) blades – Intraosseous needles (50 mm length) • Endotracheal tubes (ETT) (uncuffed, no eye, sizes 2.5, 3.0, 3.5 and 4.0 mm internal Medications diameter) – Epinephrine 1:10,000 concentration (0.1 mg/mL) • ETT introducer/stylet – Volume expander: • Supplies for fixing ETT (e.g. sterile scissors, – Normal saline (0.9% Sodium Chloride) or lac- tape) tated Ringer’s

– End-tidal carbon dioxide (CO2) detector (to con- – Blood suitable for emergency neonatal firm intubation) – Transfusion should be readily available – Meconium suction device (to apply suction directly to ETT) Documentation – Magill forceps (neonatal size - optional) – Resuscitation record sheet – Laryngeal mask (size 1, suitable for neonates up – Equipment check list to 5 kg) and 5 cc syringe

14 — — Chapter P: Neonatal Resuscitation REFERENCES 1. Kattwinkel J, Perlman JM, Aziz K, Colby C, Fairchild K, 15. Kent AL, Williams J. Increasing ambient operating the- Gallagher J, Hazinski MF, Halamek LP, Kumar P, Little atre temperature and wrapping in polyethylene improves G, McGowan JE, Nightengale B, Ramirez MM, Ringer S, admission temperature in premature infants. J Paediatr Simon WM, Weiner GM, Wyckoff M, Zaichkin J. Part 15: Child Health. 2008;44:325–331. neonatal resuscitation: 2010 American Heart Association 16. Azzopardi DV, Strohm B, Edwards AD, Dyet L, Halliday Guidelines for Cardiopulmonary Resuscitation and HL, Juszczak E, Kapellou O, Levene M, Marlow N, Emergency Cardiovascular Care. Circulation. 2010; Porter E, Thoresen M, Whitelaw A, Brocklehurst P. 122:S909–S919. Moderate hypothermia to treat perinatal asphyxia 2. Textbook of Neonatal Resuscitation, 6th Edition. encephalopathy. N Engl J Med. 2009;361:1349 –1358. 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Delayed cord clamping in very preterm infants oxygen for resuscitation of infants at birth. Cochrane reduces the incidence of intraventricular hemorrhage Database of Systematic Reviews 2005, Issue 2. Art. No.: and late-onset sepsis: a randomized, controlled trial. CD002273. DOI: 10.1002/14651858.CD002273.pub3. Pediatrics 2006;117:1235-42. 20. Davis PG, Tan A, O’Donnell CP, Schulze A. 6. Andersson O, Hellstrom-Westas L, Andersson D, Resuscitation of newborn infants with 100 percent Domellof M. Effect of delayed versus early umbilical oxygen or air: A systematic review and meta-analysis. cord clamping on neonatal outcomes and iron sta- Lancet. 2004;364: 1329-33. tus at 4 months: a randomised controlled trial. BMJ 21. Rabi Y, Rabi D, Yee W. Room air resuscitation of the 2011;343:d7157. depressed newborn: a systematic review and meta- 7. McDonald SJ, Middleton P. Effect of timing of umbili- analysis. Resuscitation. 2007; 72:353–363. cal cord clamping of term infants on maternal and 22. Hosono S, Inami I, Fujita H, Minato M, Takahashi S, neonatal outcomes. Cochrane Database Syst Rev Mugishima H. A role of end-tidal CO monitoring for 2008:CD004074. assessment of tracheal intubations in very low birth 8. Toth B, Becker A, Seelbach-Gobel B. Oxygen satura- weight infants during neonatal resuscitation at birth. tion in healthy newborn infants immediately after birth J Perinat Med. 2009;37:79–84. measured by pulse oximetry. Arch Gynecol Obstet. 23. Wiswell, TE et al. Delivery Room Management of the 2002;266:105–107. Apparently Vigorous Meconium-stained Neonate: 9. Altuncu E, Ozek E, Bilgen H, Topuzoglu A, Kavuncuoglu Results of the Multicenter, International Collaborative S. Percentiles of oxygen saturations in healthy term Trial. Pediatrics 2000;105:1-7. newborns in the first minutes of life. Eur J Pediatr. 24. Vain NE, Szyld EG, Prudent LM, Wiswell TE, Aguilar AM, 2008;167:687–688. Vivas NI. Oropharyngeal and nasopharyngeal suction- 10. Kamlin CO, O’Donnell CP, Davis PG, Morley CJ. Oxygen ing of meconium-stained neonates before delivery of saturation in healthy infants immediately after birth. their shoulders: multicentre, randomised controlled trial. J Pediatr. 2006;148:585–589. Lancet. 2004;364:597–602. 11. Gonzales GF, Salirrosas A. Arterial oxygen saturation in 25. Orlowski JP. Optimum position for external cardiac com- healthy newborns delivered at term in Cerro de Pasco pression in infants and young children. Ann Emerg Med. (4340 m) and Lima (150 m). Reprod Biol Endocrinol. 1986;15:667–673. 2005;3:46. 26. Menegazzi JJ, Auble TE, Nicklas KA, Hosack GM, Rack 12. Gungor S, Kurt E, Teksoz E, Goktolga U, Ceyhan T, L, Goode JS. Two-thumb versus two-finger chest com- Baser I. Oronasopharyngeal suction versus no suction pression during CRP CPR in a swine infant model of in normal and term infants delivered by elective cesar- cardiac arrest. Ann Emerg Med. 1993;22:240–243. ean section: a prospective randomized controlled trial. 27. Braga MS, Dominguez TE, Pollock AN, Niles D, Gynecol Obstet Invest. 2006;61:9–14. Meyer A, Myklebust H, Nysaether J, Nadkarni V. 13. Perlman JM, Volpe JJ. Suctioning in the preterm infant: Estimation of optimal CPR chest compression depth effects on cerebral blood flow velocity, intracranial in children by using computer tomography. Pediatrics. pressure, and arterial blood pressure. Pediatrics. 2009;124:e69–e74. 1983;72:329–334. 28. Barber CA, Wyckoff MH. Use and efficacy of endotra- 14. Cramer K, Wiebe N, Hartling L, Crumley E, Vohra S. cheal versus intravenous epinephrine during neonatal Heat loss prevention: a systematic review of occlu- cardiopulmonary resuscitation in the delivery room. sive skin wrap for premature neonates. J Perinatol. Pediatrics. 2006;118:1028–1034. 2005;25:763–769. 29. Perondi MB, Reis AG, Paiva EF, Nadkarni VM, Berg RA. A comparison of high-dose and standard-dose epinephrine in children with cardiac arrest. N Engl J Med. 2004;350:1722–1730.

— Chapter P: Neonatal Resuscitation — 15

30. Wyckoff MH, Perlman JM, Laptook AR. Use of volume 46. DeVita MA, Schaefer J, Lutz J, Wang H, Dongilli T. expansion during delivery room resuscitation in near- Improving medical emergency team (MET) perfor- term and term infants. Pediatrics. 2005;115:950 –955. mance using a novel curriculum and a computer- 31. Moe-Byrne T, Brown JVE, McGuire W. Naloxone for opi- ized human patient simulator. Qual Saf Health Care. ate-exposed newborn infants. Cochrane need to remove 2005;14:326–331. since Database of Systematic Reviews 2013, Issue 2. 47. Blum RH, Raemer DB, Carroll JS, Dufresne RL, Cooper Art. No.: CD003483. DOI: 10.1002/14651858.CD003483. JB. A method for measuring the effectiveness of simu- pub2. lation-based team training for improving communication 32. Field DJ, Dorling JS, Manktelow BN, Draper ES. Survival skills. Anesth Analg. 2005;100:1375–1380. of extremely premature babies in a geographically defined population: prospective cohort study of 1994–9 compared with 2000–5. BMJ. 2008;336. 33. Jain L, Ferre C, Vidyasagar D, Nath S, Sheftel D. Cardiopulmonary resuscitation of apparently stillborn infants: survival and long-term outcome. J Pediatr. 1991;118:778 –782.1221–1223. 34. Casalaz DM, Marlow N, Speidel BD. Outcome of resuscitation following unexpected apparent stillbirth. Arch Dis Child Fetal Neonatal Ed. 1998;78:F112–F115. 35. Ciaran S. Phibbs, Ph.D., Laurence C. Baker, Ph.D., Aaron B. Caughey, M.D., Ph.D.,Beate Danielsen, Ph.D., Susan K. Schmitt, Ph.D., and Roderic H. Phibbs, M.D. Level and Volume of Neonatal Intensive Care and Mortality in Very-Low-Birth-Weight Infants. N Engl J Med 2007;356:2165-75. 36. Scott A. Lorch, Michael Baiocchi, Corinne E. Ahlberg and Dylan S. Small. The Differential Impact of Delivery Hospital on the Outcomes of Premature Infants. Pediatrics 2012;130;270. 37. Lawn JE, Cousens S, Zupan J; Lancet Neonatal Survival Steering Team. 4 million neonatal deaths: When? Where? Why?Lancet. 2005 Mar 5-11;365(9462):891-900. 38. UNICEF: Extreme Risk for Pregnant Women and Newborn Babies in Developing Countries. http://www.unicef.org/media/media_47145.html. Accessed March 27, 2013. 39. Msemo G, Massawe A, Mmbando D, et al. Newborn mortality and fresh stillbirth rates in Tanzania after helping babies breathe training. Pediatrics. 2013;131:e353-e360. 40. Finer NN, Rich W, Wang C, Leone T. Airway obstruction during mask ventilation of very low birth weight infants during neonatal resuscitation. Pediatrics. 2009;123:865–869. 41. Morley CJ, Davis PG, Doyle LW, Brion LP, Hascoet JM, Carlin JB. Nasal CPAP or intubation at birth for very preterm infants. N Engl J Med. 2008;358:700–708. 42. Finer NN, Rich W, Craft A, Henderson C. Comparison of methods of bag and mask ventilation for neonatal resuscitation. Resuscitation. 2001;49:299–305. 43. Grein AJ, Weiner GM. Laryngeal mask airway versus bag-mask ventilation or endotracheal intubation for neonatal resuscitation. Cochrane Database of Systematic Reviews 2005, Issue 2. Art. No.: CD003314. DOI: 10.1002/14651858.CD003314.pub2. 44. Trevisanuto D, Micaglio M, Pitton M, Magarotto M, Piva D, Zanardo V. Laryngeal mask airway: is the management of neonates requiring positive pressure ventilation at birth changing? Resuscitation. 2004;62:151–157. 45. Wayne DB, Butter J, Siddall VJ, Fudala MJ, Linquist LA, Feinglass J, Wade LD, McGaghie WC. Simulation-based training of internal medicine residents in advanced cardiac life support protocols: a randomized trial. Teach Learn Med. 2005;17:210 –216.

16 — — Chapter P: Neonatal Resuscitation Chapter Q Cesarean Delivery Neil J. Murphy, MD, FACOG, FAAFP slide 1 Sarah K. Jorgensen, DO Jeffrey D. Quinlan, MD, FAAFP

Published March 2012

OBJECTIVES slide 2 After completing this chapter, participants will be able to: 1. Describe the anatomy and physiology relevant to cesarean delivery. 2. List eight steps leading to cesarean delivery of a fetus. 3. Discuss five intra-operative and five post-operative complications of cesarean delivery. 4. Describe the indications for perimortem cesarean delivery.

INTRODUCTION The Joint American Academy of Family Physicians (AAFP)/American College of Obstetricians and Gynecologists (ACOG) Recommended Curriculum Guidelines for Family Medicine Residents: Maternity and Gynecologic Care describes core and advanced obstetric training for family physicians.1 This chapter will review cesarean delivery within the contexts of family physicians, OB/GYN residents, CNMs or registered nurses requesting cesarean delivery consultation, surgical first assisting, performance of cesarean delivery as the primary surgeon, perimortem cesarean delivery, and vaginal trial of labor after cesarean (TOLAC).

History The origin of the term “cesarean” is not entirely clear. It is unlikely that Julius Caesar was born by abdominal delivery, as this was almost universally fatal for the parturient during that era and Caesar’s mother is known to have survived his birth.2 Another possible origin of the term is the Latin verb cae- dere, which means “to cut”. Others believe the term originated from the Roman custom, Lex Cesare, which mandated postmortem operative delivery when mothers died during childbirth, so that mother and child could be buried separately.

The term “cesarean section” is also a matter of discussion. The term is a tautology — using different words to say the same thing twice — where the additional words fail to provide additional clarity while repeating a meaning. In this case both words refer to an incision. A more proper term for the procedure is ‘cesarean delivery’.

EPIDEMIOLOGY Frequency slide 3 The cesarean delivery rate in the U.S. increased from 4.5 percent in 1965 to an all-time high of 32.3 percent in 2008.3-4 This represents an increase of 56 percent from the 20.7 percent rate in 1996.4 The increase is a result of both the increase rate of primary cesarean deliveries and the decrease in vaginal birth after cesarean.

— Chapter Q: Cesarean Delivery — 1 Goals for Cesarean Delivery Rates The ACOG Task Force on Cesarean Delivery Rates recommends using case mix adjusted rates and has offered the following benchmarks:5 • Nulliparous women at 37 weeks of gestation or greater with singleton fetuses with cephalic presentation. The national delivery rate for this group was 17.9 percent; the expert working group goal at the 25th percentile for this group is 15.5 percent. • Multiparous women with one prior low transverse cesarean delivery at 37 weeks of gestation or greater with singleton fetuses with cephalic presentations. The national 1996 TOLAC rate for this group was 30.3 percent; the expert working group goal at the 75th percentile is 37 percent.

MORBIDITY AND MORTALITY The maternal mortality rate for elective repeat cesarean delivery is 13.4 per 100,000 births.6 Half of these deaths are related to intraoperative complications, while others are related to anesthetic and post-operative complications. In recent years, there has been a shift in the etiology of deaths from hemorrhage and infection to thromboembolic events.

INDICATIONS The most common indications for cesarean delivery in North America are repeat cesarean (30 percent), dystocia or failure to progress (30 percent), malpresentation (11 percent), and Category III fetal heart rate tracings (10 percent).7 Other indications are listed in Table 1. Many indications are dependent on other clinical factors, e.g., viral load with HIV, unable to meet criteria for vaginal breech delivery and current status of medical conditions.

Table 1. Common Indications for Cesarean Delivery slides 4-6 Fetal Maternal-Fetal Maternal Category III Fetal Heart Rate Tracing Failure to progress Repeat cesarean delivery Malpresentation in labor: Contracted pelvis • Transverse lie • Arrest of descent • Congenital • Breech • Arrest of dilation • Fracture • Brow Placental abruption Obstructive tumors • Face/Mentum posterior Placenta previa Abdominal cerclage Cord prolapse Conjoined twins Reconstructive vaginal surgery Human Immunodeficiency Virus Perimortem Medical conditions (e.g., cardiac, Active herpes virus pulmonary, thrombocytopenia) Congenital anomalies Vasa previa

CONTRAINDICATIONS There are few contraindications for cesarean delivery. A guiding principle is “what is best for the fetus is what is best for the mother”. If the mother is medically unstable and the fetus is non-viable, then it is recommended that the maternal condition be stabilized regardless of fetal consideration. If the fetus is of a gestational age consistent with viability, then the maternal condition should also be stabilized first and delivery considered only for obstetric indications. The exception to this dictum is perimortem cesarean delivery.

2 — — Chapter Q: Cesarean Delivery TIMING OF ELECTIVE CESAREAN DELIVERY slide 7 While term pregnancy is defined as 37 weeks of gestation or later; elective cesarean delivery is typically not performed prior to 39 weeks gestation secondary to the risk of fetal lung non-maturity. Despite this risk, Tita et al demonstrated that over one third of elective cesarean deliveries completed at their facility between 1999 and 2002 were done before 39 weeks gestation. Additionally, they demonstrated that delivery prior to 39 weeks was associated with increased rates of respiratory problems, sepsis, hypoglycemia, and either prolonged hospitalization or requirement for increased level of care.90 Therefore, cesarean should not be performed prior to 39 weeks gestation unless there are medical indications for either the mother or fetus.

For patients with complicating factors (e.g. placenta previa or prior classical uterine incision), risk of maintaining the pregnancy to 39 weeks may outweigh the risks to the mother and fetus if delivered prior to 39 weeks. In these situations, consideration should be given to obtaining an amniocentesis for fetal lung maturity beginning at 36 weeks. Once fetal lungs are determined to be mature or the patient reaches 38 weeks of gestation, cesarean delivery should be performed.

ANATOMY AND PHYSIOLOGY slides 8-9 Many alterations in maternal cardiovascular physiology during pregnancy are relevant to cesarean delivery. (See Chapter K. Maternal Resuscitation) These physiologic changes increase maternal blood volume and flow in the pelvic organs, rendering the woman more susceptible to serious hemorrhage during cesarean delivery. The surgical anatomy is described in this chapter with each aspect of the procedure. An understanding of pelvic blood supply of pelvic blood supply is essential for physicians performing a cesarean delivery.

Uterine Artery The aorta bifurcates into bilateral common iliac arteries at the level of the fourth lumbar vertebra. The common iliac divides into external and internal iliac arteries. The internal iliac or hypogastric artery drops medio-inferiorly along the border of the psoas muscle and divides into anterior and posterior divisions. The anterior division has both parietal and visceral branches of variable origin.

The uterine artery, a main visceral branch of the anterior division of the hypogastric artery, descends for a short distance, enters the base of the broad ligament, and turns medially to the lateral aspect of the uterus. The relationship between the uterine artery and ureter is surgically significant. About two centimeters lateral to the cervix, the uterine artery crosses over the ureter. The ureter can be injured in the process of clamping and ligating the uterine vessels in postpartum hemorrhage or during hysterectomy.

The inferior branch of the uterine artery supplies the upper vagina and the lower cervix, while the marginal branch traverses the lateral aspect of the uterus before dividing into three terminal branches: ovarian, tubal, and fundal. Near the upper lateral portion of the uterus, the ovarian artery anastomoses with the ovarian branch of the uterine artery. Throughout its length, the marginal branch is a convoluted vessel with numerous branches penetrating the body of the uterus, including one large branch that extends to the upper portion of the cervix.

— Chapter Q: Cesarean Delivery — 3 Ovarian Artery The ovarian artery is a direct branch of the aorta and enters the broad ligament through the infun- dibulopelvic ligament. At the ovarian hilum, the ovarian artery divides into ovarian branches and a main branch that traverses the broad ligament.

Uterine and Ovarian Veins The lateral uterus is composed largely of venous sinuses. These sinuses coalesce into arcuate veins that unite to form the uterine vein. Several large uterine veins accompany the uterine artery and empty into the hypogastric vein, which empties into the common iliac vein. The ovarian vein collects blood from the upper part of the uterus through a large pampiniform plexus in the broad ligament. The right ovarian vein empties into the vena cava, while the left ovarian vein empties into the left renal vein.

Vaginal Blood Supply The vagina receives blood from the inferior extension of the uterine artery along the lateral sulci of the vagina and from a vaginal branch of the hypogastric artery. These form an anastomotic arcade along the lateral aspect of the vagina at the 3:00 and 9:00 o‘clock positions. Branches of these vessels also merge along the anterior and posterior vaginal walls.

PHYSICAL FINDINGS AND DIAGNOSIS slide 10 History History should be obtained that is pertinent to impending surgery, including medical, surgical, obstetric, gynecologic, family, drug habits, transfusion, medication, allergy, and anesthetic. Information about the current obstetric indication is required, e.g. length of labor and duration of ruptured membranes.

Physical Examination The physical examination for cesarean delivery should address major medical, obstetrical, and anesthetic concerns. The operating team must be cognizant that regional anesthesia may be converted to general anesthesia at any time during the procedure. A vaginal exam should be performed in all laboring patients just prior to surgical draping, to assure that sufficient progress in labor has not occurred that would permit vaginal delivery.

Ancillary Tests Pre-operative laboratory evaluation should include hemoglobin, blood type, and Rh factor. A blood clot tube should be present in the blood bank for blood typing and antibody screening in the event that transfusion is required. HIV status should be known on all prenatal patients so that measures can be taken to decrease the risk of vertical transmission of infection. If the cesarean delivery is being considered because of abnormal fetal heart monitoring that does not resolve with conservative measures then additional testing may be indicated because of the high rate of false positive tests with electronic fetal monitoring (EFM). (See Chapter E. Intrapartum Fetal Surveillance) Methods for confirmatory testing include fetal response to scalp or acoustic.

4 — — Chapter Q: Cesarean Delivery PROCEDURE Pre-Operative and Non-Surgical Considerations The patient should be prepared as for any major abdominal procedure. Additional fluids are necessary for regional anesthesia, increased insensible loss with labor, and intra-operative loss of 1,000 cc per hour due to exposed viscera and blood loss. (Table 2)

Table 2. Pre-operative Preparation/Orders slide 11 Vital signs and non-stress test on admission Anesthesia consultation Nothing per mouth (except non-particulate citrate antacid, Bicitra®) Intravenous: Lactated ringers at 125 cc/hr; if regional anesthetic, then bolus of IV fluids per Anesthesia Bicitra® 30 cc per mouth 1 hour pre-op, or on call to OR Cefazolin (Ancef®) one gram intravenous to be given 15 to 60 minutes prior to skin incision Place patient in left lateral decubitus position Insert bladder catheter Clip lower abdominal hair as needed Sequential compression devices on lower extremities Lab: Complete blood count, blood type and screen Patient education: cesarean delivery

Fluid administration prior to epidural or spinal anesthesia in normotensive patients usually involves a 1,000 cc bolus of isotonic fluids. Isotonic fluids are good first-line agents in the event of excessive bleeding, but blood product replacement is necessary for any ongoing blood loss greater than 1,000 ml. Use of prophylactic antibiotics has been shown to decrease the incidence of fever, endometritis, wound infection, urinary tract infection and serious post operative infection after cesarean delivery.8 Both ampicillin and first generation cephalosporins have similar efficacy in reducing postoperative endometritis. There does not appear to be added benefit in utilizing a broader spectrum agent or a multiple dose regimen.9 All cesarean delivery patients should receive intravenous antibiotics prior to skin incision, unless the patient is already receiving appropriate antibiotics (e.g., for chorioamnionitis) or there is not adequate time due to a “crash” cesarean delivery10-11 Preincision prophylaxis is advantageous for the mother and not harmful to the neonate therefore the prior practice of administering antibiotics after cord clamping has been abandoned. Consider clindamycin in patients who are penicillin allergic with a history of anaphylaxis, urticaria or other life threatening reaction, if a procedure exceeds four hours, then re-dosing should be considered.

Infective endocarditis prophylaxis is no longer recommended for vaginal or cesarean delivery in the absence of infection, regardless of the type of maternal cardiac lesion.12 Abdominal hair removal often is not necessary. If hair is removed, it should be removed in the operating room and not the evening before the procedure. The hair should be clipped and not shaved to decrease the risk of infection.

Informed Consent The surgeon should thoroughly discuss the risk and benefits of the procedure in both non-medical and medical terminology with the patient and a family member, if available. The counseling is best documented in narrative form, though a preprinted form can be used. Preoperative documentation should be signed and dated by the patient and surgeon. Documentation should include diagnosis,

— Chapter Q: Cesarean Delivery — 5 procedure, common and important risk factors, alternatives to the proposed procedure, and other such procedures as anticipated as being possibly needed in the judgment of the surgeon (e.g. tubal ligation or oophorectomy for known adnexal mass). The risk factors can be simplified to bleeding, infection, internal organ damage, anesthesia risk, hysterectomy, injury to fetus and risk of maternal death.

CESAREAN DELIVERY PROCEDURE The primary surgeon and assistant should both carefully review the following basic skill discussion. (Table 3)

Table 3. Techniques of Cesarean Delivery

Prepare patient Clamp and cut umbilical cord slide 12 • Informed consent • Obtain cord blood for: • Nothing by mouth except non- – Type and Direct Coombs, if clinically particulate antacid, anesthesia, indicated13 bladder catheter – Cord pH from loop of cord obtained • Clip hair, cleanse skin, left lateral decubitus position prior to cord blood sample • Cefazolin IV within 60 minutes prior to skin incision • Delivery of placenta • Sequential compression devices on lower • Assisted spontaneous extremities • Manual Abdominal wall incision Cleanse uterine cavity • Joel-Cohen • Place ring forceps at apices (Misgav Ladach modification) of uterine incision • Modified Pfannenstiel Uterine closure

• Midline vertical • Externalize uterus (optional) • Others: Maylard, Cherney • Inspect for possible extensions Fascial incision • One to two layers of absorbable • Joel-Cohen: small midline fascial suture incision, stretch tissue Inspect pelvic and abdominal contents • Pfannenstiel: long transverse incision, • Remove foreign material from separate rectus muscle/ sheath, stretch peritoneal cavity rectus muscles apart • Sponge and needle count Peritoneal incision Peritoneal closure (optional) • Parietal: Longitudinal; Transverse (Joel-Cohen) • Visceral (bladder flap) • Visceral: Transverse vesicouterine; +develop blad- • Parietal der flap Fascial closure Uterine incision • Single non-locking • Low transverse • Two lines of suture meeting in the • Classical midline, non-locking (optional) • Low vertical Subcutaneous (optional, if tissue greater Elevate the fetal presenting part than two centimeters) • Elevate presenting part, maintain flexion if cephalic • Close dead space if > 2 cm • Second assistant to dislodge presenting part, if • Irrigate subcutaenous tissue deeply seated Skin closure: subcuticular, staples, widely Apply fundal pressure spaced mattress sutures • Administer oxytocin after delivery of presenting part Apply sterile dressing

6 — — Chapter Q: Cesarean Delivery ABDOMINAL WALL INCISION slide 13 Options for the abdominal wall incision include the modified-Pfannenstiel, Joel-Cohen, and midline vertical incisions, plus several variants of these incisions.14 The midline vertical incision was said to be quickest abdominal wall incision, but most experienced surgeons can perform either the Joel- Cohen within seconds or the modified Pfannenstiel within minutes.

Modified Pfannenstiel The modified-Pfannenstiel incision is made three centimeters above the pubic symphysis. The incision is extended beyond the lateral borders of the rectus muscles in a curvilinear fashion to within two to three centimeters inferior and medial of the anterior superior iliac crests. The incision may be placed under the pannus in very obese patients, however this area is heavily colonized with bacteria and may be difficult to prepare surgically, keep dry, and to inspect in the post-operative period.

The subcutaneous tissues are completely separated from the fascia and a transverse incision is made through the fascia. The fascial sheath is then completely separated from the underlying rectus muscles by blunt and sharp dissection to the umbilicus and caudad until the pubis is palpable. Blood vessels perforating through the muscles can be ligated with electrocautery, or cut and clamped as required for hemostasis. The peritoneum is elevated and sharply opened longitudinally in the midline. slide 14 Joel-Cohen (Misgav Ladach Modification) The Joel-Cohen abdominal wall incision, modified by the Misgav Ladach hospital, emphasizes stretching tissue within existing planes, rather than sharp dissection.15 (Table 4)

Joel-Cohen-based cesarean delivery compared with Pfannenstiel cesarean delivery was associated with reduced blood loss, operating time, time to oral intake, fever, duration of postoperative pain, analgesic injections, and time from skin incision to birth of the neonate.14

Available evidence suggests that the Joel-Cohen–based techniques (Joel-Cohen, Misgav-Ladach, and modified Misgav-Ladach) have advantages over Pfannenstiel and traditional CS techniques in relation to short-term outcomes. There is no evidence in relation to long-term outcomes.14 slide 15 Table 4. Misgav Ladach Method of Cesarean Delivery16

1. Modified Joel-Cohen opening of the abdomen 2. Parietal peritoneum opened transversely 3. No abdominal swab used 4. Lower uterine segment transverse incision 5. Uterus sutured continuously in one layer 6. Visceral and parietal peritoneum left open 7. Non-locking continuous closure of the fascia 8. Few widely spaced skin stitches

Reprinted from the International J of Gynecol and Obstet, 1997;57:p 273, Federici D, Lacelli B, Muggiasca A, et al: Cesarean section using the Misgav Ladach method, with permission from Elsevier.

— Chapter Q: Cesarean Delivery — 7 This technique has particular advantages in remote or rural areas because it requires fewer instruments than other methods for opening the abdominal wall, and can be performed quickly. The modified Joel-Cohen begins with a transverse incision, 15 to 17 centimeters long, made three centimeters below the anterior superior iliac crests. The skin is opened superficially, followed by sharp dissection of the subcutaneous fat to open the fascia in the midline only.

The fascia is extended sharply two to three centimeters under the intact subcutaneous tissue. After opening the fascia, the remaining subcutaneous tissue, fascia, and rectus muscles are dissected bluntly. The fascia is best opened with cephalad and caudad pressure followed by transverse pressure on the rectus muscles laterally.

The incision is very rapid and results in less blood loss than other techniques. There is a decreased need for transfusion and less risk of HIV transmission because the technique simply stretches tissues transversely.

Decreased tissue damage also leads to less post-operative analgesia and early resumption of feeding and activity. Joel-Cohen-based cesarean delivery compared with Pfannenstiel cesarean delivery was associated with reduced blood loss, operating time, time to oral intake, fever, duration of postoperative pain, analgesic injections, and time from skin incision to birth of the neonate.14

Midline Vertical The midline-vertical skin incision extends from the pubic symphysis to within two centimeters of the umbilicus. The fascia is elevated and sharply dissected from the pubis to the umbilicus. This midline-vertical abdominal wall incision can be performed rapidly, and provides excellent exposure of the pelvis and sidewalls.

Other Incisions The transverse Maylard rectus-cutting incision begins with a curvilinear skin incision that extends 18 to 19 centimeters between the anterior superior iliac crests. The Maylard offers maximal exposure for abnormal lie, multiple gestation, or macrosomia. In the transverse Cherney incision, the rectus muscles are detached from their insertion at the pubic symphysis. The transversalis fascia and peritoneum are incised transversely in the Cherney, as opposed to the longitudinal Pfannenstiel approach.

PERITONEAL INCISION slide 16 Parietal Peritoneum The parietal peritoneum should be entered as high as possible to avoid inadvertent bladder injury, especially in repeat procedures. After the Pfannenstiel and midline-vertical incisions, the parietal peritoneum is sharply incised from the umbilicus to the bladder. In the Joel-Cohen, the peritoneum is stretched in a transverse direction.

Urinary bladder The urinary bladder can be divided into two portions, the dome and base. The base of the bladder, which rests on the upper vagina and cervix, contains the trigone and is contiguous with the muscle of the vesical neck and urethra. The muscular dome of the bladder is relatively thin when distended. The bladder base is thicker and varies less with distention. The bladder is encountered twice before

8 — — Chapter Q: Cesarean Delivery delivery. Initially the surgeon visualizes the bladder when opening the peritoneum and it is encountered again when dissecting the bladder flap off the lower uterine segment. The extent of the bladder can be confirmed by palpation of the catheter bulb or transillumination. slide 17 Visceral Peritoneum Omission of the bladder flap provides short-term advantages such as reduction of operating time and incision-delivery interval, reduced blood loss, and need for analgesics.17 Long-term effects remain to be evaluated. In those cases in which a cesarean hysterectomy is planned, then developing a bladder flap may be helpful.

If deemed necessary, the vesico-uterine peritoneum is elevated and opened transversely one centimeter above the bladder reflection onto the lower uterine segment. The bladder flap is bluntly and sharply developed transversely 10 to 12 centimeters, then inferiorly five centimeters, to the level of the bladder’s apposition to the cervix. slide 18 UTERINE INCISION Cesarean delivery is performed via one of several uterine incisions. The most common is a low- transverse or Kerr incision. A less common surgical approach is the “classical” or vertical uterine incision. Both can be performed through any abdominal incision.

Uterus As the uterus enlarges, it reaches almost to the liver displacing the intestines laterally and superiorly. The uterine musculature is arranged in three layers. The muscle cells in the middle layer are interlaced such that when they contract after delivery, they constrict the perforating blood vessels. When a pregnant woman is supine, however, her uterus falls back to rest upon the vertebral column and the great vessels, especially the aorta and the inferior vena cava. With ascent from the pelvis as pregnancy progresses, the uterus undergoes dextro-rotation, resulting in the left margin facing anteriorly. slide 19 Low transverse incision The low-transverse Kerr incision is made in the inactive or non-contractile lower uterine segment. Most cesarean deliveries use a low-transverse uterine incision because of the ease of delivery and low rate of both immediate and subsequent wound dehiscence. The low incidence of dehiscence occurs because the low-transverse incision avoids the active uterine segment. It also requires less surgical repair, results in less blood loss and is less likely to result in formation of adhesions to the bowel or omentum.

The lower uterine segment is delicately scored in the median aspect with a scalpel, one to two centimeters from the upper margin of the bladder taking care to avoid injury to the fetus. If the lower uterine segment is very thin, fetal laceration injury, which occur in between 0.7 and 1.9 percent of cesarean deliveries,18-19 can be avoided by elevating the lower uterine segment with Allis clamps. Another method involves cutting to within a few cells of the uterine cavity, then tapping the closed blades of a pair of scissors against the incision. Opening and closing the blunt tips of the scissors will not hurt the baby, nor enter the amniotic cavity, but will penetrate the remaining layers of lower segment.

— Chapter Q: Cesarean Delivery — 9 The uterine incision is extended bluntly using two fingers. Blunt expansion of the uterine incision by separating the fingers in a cephalad-caudad direction results in less unintended extension and blood loss than expansion in a transverse direction.20 The incision should extend approximately 10 centimeters transversely and slightly cephalad in a curvilinear fashion. If the uterine wall is thickened or there is need for an extension, then bandage scissors should be used. In this case, care should be taken to avoid injury to the fetus or umbilical cord. The incision should be large enough to avoid fetal injury and to avoid inadvertent extension into lateral vessels. If it is necessary to extend the uterine incision, then the first superior curvilinear incision should be to the right to avoid the lateral vessels because of the dextro-rotation. Some surgeons place laparotomy sponges in the peritoneal cavity to minimize contamination with chorioamnionitis or thick meconium. All laparotomy sponges placed in the abdomen should have radio-opaque tails. The surgeon should know the location of every sponge in the abdomen, and not simply rely on the operating team’s count. slide 20

Classical / Vertical Incision The classical uterine incision is made vertically into the active myometrium. The classical incision is indicated in significant prematurity with a poorly developed narrow lower uterine segment, dense adhesions, or structural uterine abnormalities, e.g., myoma in the lower uterine segment or Bandl’s contractile uterine ring. The classical incision may be used in some cases of anterior placenta previa and malpresentation, e.g., back-down transverse lie, pre-term breech, and interlocking twins.

Low vertical incision The low vertical incision begins as inferiorly as possible to avoid the active uterine segment. The incision is usually made about two centimeters above the bladder, and is carried as far cephalad as necessary to allow facile delivery. This may be performed completely in the lower uterine segment and repair may be as strong as the low transverse incision. Shipp et al suggest that there is no increased risk of uterine rupture in future pregnancies when a low vertical uterine incision is used compared to a low transverse incision.21

The major disadvantage of the low vertical incision is the possibility of extension cephalad into the uterine fundus or caudally into the bladder, cervix, or vagina. It is also difficult to determine that the low vertical incision is truly low, as the separation between lower and upper uterine segments is not easily identifiable clinically.

Anterior Placenta Management If an anterior placenta is present, it should be dissected or separated from the uterine wall facilitating exposure of the fetus. There is a short-term risk of fetal hemorrhage unless delivery is rapid. If the placenta is lacerated, the operator should cut through the rest of the placenta and quickly delivery the infant and clamp the cord. A vertical incision may be necessary. A preoperative ultrasound for placental location may be helpful. slide 21 slide 22 DELIVERY OF THE FETUS Cephalic Presentation To deliver an infant from a cephalic presentation, remove the retractors and elevate the presenting part with the operator’s hand, after which the assistant applies transabdominal pressure to the uterine fundus. If the presenting part is deeply applied to the cervix, then gently insinuate the hand into the uterus with side-to-side motions to break the suction and act as lever to elevate the presenting

10 — — Chapter Q: Cesarean Delivery part. The operator should avoid using the uterine incision as a fulcrum for elevating the presenting part to avoid extension of the uterine incision. The assistant applies fundal pressure when the operator feels the presenting part is elevated enough that the force will push the presenting part up and out of the incision instead of deeper into the pelvis. Flexion is desirable in both occiput posterior or anterior. Too much manipulation of a thin lower uterine segment may lead to a deep cervical laceration. If the presenting part is deeply seated in the pelvis, then an additional assistant may need to go under the operative drapes to manually dislodge the presenting part cephalad via the vagina.

If the presenting part is high, then a vacuum extractor or single blade of a Simpson forceps may be helpful. Deliver the torso by gently working the shoulders out one at a time with continued fundal pressure. The infant is transferred to an attendant after the umbilical cord is clamped and cut.

Breech Presentation The presenting part should be confirmed pre-operatively with ultrasound, as a breech presentation will require a slightly larger abdominal wall and uterine incision for adequate exposure. A vertical uterine incision may be necessary if the lower uterine segment is not well developed, e.g., very preterm. The techniques for a breech cesarean delivery are similar to those used in a breech vaginal delivery. (See Chapter G. Malpresentation) The abdominal and uterine incisions can be extended if delivery of the fetal head is difficult. The uterine incision can be extended vertically into the active myometrium, perpendicular to the transverse uterine incision in an inverted ‘T’ shape, or extended perpendicularly to the uterine vessels in a ‘J’ shape. These extensions should be noted in the operative report and the patient informed that repeat cesarean is indicated in future pregnancies due to increased risk of uterine rupture.

After Delivery of the Fetus Cord blood is obtained and may be sent for infant blood type and Rh status, Coombs test, HIV or RPR based on facility guidelines.13 In addition, a 10 to 15 centimeter segment of umbilical cord may be saved for blood gas measurement. To obtain a sufficient amount of arterial pH specimen, the slide 23 cord should be clamped close to the placenta.

DELIVERY OF THE PLACENTA An infusion of 20 to 40 units of oxytocin (Pitocin®) in a liter of isotonic crystalloid is begun immediately upon delivery. Assisted spontaneous delivery of the placenta involves fundal massage and gentle traction on the umbilical cord. Manual extraction of the placenta may be necessary on occasion, but assisted spontaneous delivery of the placenta with gentle cord traction is preferred.

Assisted spontaneous delivery of the placenta with cord traction at cesarean delivery has advantages compared to manual removal. It results in fewer instances of endometritis; less blood loss; less decrease in hematocrit levels postoperatively; shorter duration of hospital stay, and it does not add significantly to operative time.22

The uterine cavity should be inspected and cleansed with a laparotomy sponge. Routine manual/instrumental cervical dilatation before closing the uterus in an elective cesarean delivery is unnecessary. A RCT reported that this practice does not improve blood loss and postoperative infectious morbidity.23

— Chapter Q: Cesarean Delivery — 11 REPAIR OF THE UTERUS slides 24-25 The uterus can be repaired within the peritoneal cavity or while externalized. There is no evidence from the latest Cochrane review to make definitive conclusions about which method of uterine closure offers greater advantages.24 Externalization offers increased exposure of the uterus and adnexa, plus ease of fundal massage.

No differences in complication rates were found between extraabdominal and intraabdominal repair at cesarean delivery.25 In addition, there was no difference in rates of intraoperative nausea/vomiting among those who underwent cesarean delivery under regional anesthesia.25

Significant bleeding points should be clamped with ring forceps and the fundus of the uterus covered with a moist sponge. The margins of the uterine incision should be identified. The uterine incision is closed with a single layer of zero or number one absorbable suture in a running-locked manner.

The surgeon traditionally sutures toward her/himself. To insure that each apex is closed, a suture should be placed just beyond each apex. Some surgeons add a second line of sutures to imbricate the incision and for hemostasis. There is conflicting evidence regarding the advantage of the second suture layer.26-27 Patients who have a single layer closure may be at increased risk of uterine rupture during the next pregnancy compared with those who undergo a two-layer closure. For women who would consider a trial of labor after a previous cesarean delivery, a two-layer uterine closure is suggested, although data to support this is not conclusive. Closure of a vertical incision requires a layered closure, using successive layers of zero or number one absorbable suture.

CLOSURE OF PERITONEAL, FASCIAL, slides 26-28 SUBCUTANEOUS AND SKIN LAYERS Following exploration of the pelvis and abdomen, all foreign material should be removed from the pelvis and copious lavage accomplished, especially if chorioamnionitis is present. It is essential to confirm that needle and sponge counts are correct. In the past, the vesicouterine and parietal peritoneum were closed with a 2-0 absorbable suture. Closure of the peritoneum offers no advantage, and increases operative time, febrile morbidity, rates of cystitis, narcotic use, antibiotic use, and length of stay in the hospital. There was improved short-term postoperative outcome if the peritoneum was not closed.28

The fascia is closed with a zero or number one non-locked continuous long-lasting absorbable suture, e.g., polyglactin 910 (Vicryl®). Sutures should be placed at one centimeter intervals approximately one and one half centimeters from the margin of the cut fascia. Some surgeons close the fascia with two lines of suture that meet in the midline. Many surgeons perform a Smead-Jones mass closure with a number one non-absorbable suture for vertical incisions at high risk of dehiscence.

Suture closure of subcutaneous fat during cesarean delivery results in a 34 percent decrease in risk of wound disruption in women with fat thickness greater than 2 cm.29-30 The skin can be closed with staples, subcuticular 4-0 absorbable sutures, skin adhesive, or with widely spaced mattress sutures. Studies have shown no clear difference in strength of incision closure or cosmetic appearance with the various techniques.31-34

12 — — Chapter Q: Cesarean Delivery TIPS FOR SURGICAL ASSISTANCE AT CESAREAN DELIVERY The surgical assistant plays a key role in cesarean delivery. (Table 5) The key elements are maintaining excellent exposure and maintaining the flow of the procedure, and being prepared for the unexpected. (Table 5)

Table 5. Tips for Surgical Assistance at Cesarean Delivery slides 29-31 Exposure Lateral aspects of the following on both opening and closing: Rectus fascia, vesicouterine peritoneum, uterus Rectus fascia (with modified Pfannenstiel incision) Elevate fascia with Kocher clamps Blunt dissection of rectus muscle from fascia Provide counter traction on muscle while surgeon dissects fascia from muscle Re-check under fascia for bleeding before closure Uterine incision Suction blood and fluid from incision as surgeon delicately scores uterus sharply Delivery Apply fundal pressure when requested Assist with clamping and cutting umbilical cord Obtain cord blood samples If uterus is externalized after delivery Hold tension on fundus while keeping the uterine incision dry for visualization of repair Scrub technician should create exposure with bladder blade Uterine closure If surgeon is locking sutures, then loop suture over needle each pass Knot tying Three loops or throws for chromic gut suture Four loops or throws for Vicryl®, with first being a double throw or surgeon’s knot

TECHNICAL PITFALLS slide 32 Closing the Uterine Incision A common error is placement of sutures beyond the uterine incision. This may result in increased bleeding from the lateral uterine vessels, and increases ureteral injury. An inexperienced operator, or one operating with inadequate exposure, may inadvertently suture incorrect tissue. The uterine incision, and any extensions, should be carefully identified prior to closure. Poor exposure may result in suturing the upper edge of the uterine incision to a prominent posterior wall of the uterus.

Malpresentation Deliveries slide 33 Some experienced clinicians consider converting a breech or transverse to cephalic after opening the abdomen but before the uterine incision. Intraoperative version prior to uterine incision may avoid a traumatic delivery, a classical uterine incision, an inverted “T” incision, or an extension. Adequate abdominal wall and uterine exposure is critical for atraumatic delivery of a malpresentation. A skilled assistant must be available to avoid hyperextension and assist with fetal head flexion when performing a cesarean delivery of an infant in breech presentation.

— Chapter Q: Cesarean Delivery — 13 Postoperative Care While it was customary for fluids and/or food to be withheld for a period of time after abdominal operations, there was no evidence from randomized trials reviewed to justify a policy of withholding oral fluids after uncomplicated cesarean delivery.35

Choice of Procedure Randomized-controlled studies have shown that many aspects of the traditional cesarean delivery slide 34 practiced in the US are unnecessary. The modified Joel-Cohen cesarean delivery avoids these steps, and is associated with less operative time, fewer complications, and shorter length of stay.14

Uterine closure with interrupted or single-layer continuous locking suture has short-term benefits. However, the evidence from observational studies of an increased risk of scar rupture may favor the use of double-layer closure pending evidence on this outcome from randomized trials.27

Where no clear benefits of one method over another have been shown, the choice may have been influenced by the clinical setting. For example, in a resource-constrained environment where large numbers of cesarean deliveries are performed, a cost-effective choice may be spinal analgesia and Joel-Cohen–based surgical methods, which require only two lengths of suture material for the operation, and double-layer closure of the uterus.14

Summary of Cesarean Delivery Techniques 1. No preoperative hair removal; or clipping or depilatory creams on the day of surgery or the preceding day (no shaving). 2. No specific antiseptic for preoperative bathing. 3. Antibiotic prophylaxis with ampicillin or a first-generation Cephalosporin.9 4. Double gloving is advised in areas with high rates of bloodborne infections to achieve fewer perforations in inner glove and prevent needle stick injuries. 5. Transverse lower abdominal wall opening and uterine opening using Joel-Cohen–based methods.15 6. Bladder peritoneum may be reflected downward or not.17 7. Placental removal with cord traction.22 8. Intraabdominal or extraabdominal repair of the uterus.24 9. Uterine closure with interrupted or single-layer continuous locking suture has short-term benefits. However, the evidence from observational studies of an increased risk of scar rupture may favor the use of double-layer closure pending evidence on this outcome from randomized trials.26-27 10. Nonclosure of both peritoneal layers.28 11. Closure of the subcutaneous tissues if greater than 2 cm thickness.29-30 12. No routine drainage of the subcutaneous tissues.36 13. Skin closure with subcuticular or interrupted sutures, staples, or tissue adhesive.31 14. No withholding of oral fluids after surgery.35

14 — — Chapter Q: Cesarean Delivery slide 35 Poor Documentation in Operative Reports Accurate documentation of the operative procedure can prevent confusion and complications in the future. In particular, the surgeon should take care in describing the uterine incision. For example, “repeat low-transverse cesarean delivery” can be ambiguous to some. It could mean: • the prior incision was a classical or low vertical and the current procedure was a “repeat” cesarean performed via a low-transverse incision, or • the previous operation was a low-transverse incision and the same procedure was used in the current procedure.

In the first example, the patient should never undergo TOLAC, while in the second she is a TOLAC candidate. A better description of the procedure would be “Low-transverse uterine incision. Repeat cesarean delivery” It is also important to properly document the extent of active uterine segment involved in a low-vertical incision, the extent of an inverted “T” incision, and the nature of any uterine lacerations. The dictation should also contain a brief description of the ovaries, tubes, and surrounding structures. slide 36 INTRAOPERATIVE COMPLICATIONS Intraoperative injuries are uncommon, but they can still occur despite careful attention to technique. The operative team is responsible for identifying and repairing injuries, or seeking appropriate assistance.

Hemorrhage The most common cause of hemorrhage during cesarean delivery is uterine atony. The first management steps are uterine massage and pharmacological therapy, then surgical management. Pharmacological therapy should proceed in a stepwise fashion from oxytocin (Pitocin®) 20 to 40 units per liter intravenously, to methylergonovine (Methergine®) 0.2 milligrams intramuscularly, to F2a 15-methyl prostaglandin (Hemabate®). The initial dose of F2a 15-methyl prostaglandin is 0.25 milligrams. That dose can be repeated every 15 minutes to a maximum dose of 2.0 milligrams. 15-methyl-Prostaglandin F2α (hemabate) can be administered intramuscularly or directly into the myometrium. (See Chapter J. Postpartum Urgencies). Misoprostol can be used as an alternative to 15-methyl-PGF2α. In an awake alert patient 400 mcg may be given subingual or buccal or 800 mcg per rectum.

The surgical management of hemorrhage should also proceed in a step-wise fashion depending on the patient’s hemodynamic status. The first step is bilateral O’Leary sutures of the uterine arteries. (Slide 37) These zero or number one absorbable sutures are placed in the lateral aspect of the uterus, just cephalad to the ureter. A second step to decrease uterine bleeding if the O’Leary sutures are not sufficient is bilateral ligation of the uterine vessels just medial to the ovaries.

Next, uterine compression sutures are an effective method for reducing PPH and avoiding hysterectomy. Limited follow-up of women who have had a uterine compression suture suggests that there are no adverse effects on future pregnancy The B-Lynch suture envelops and compresses the uterus, similar to the result achieved with manual uterine compression.37 In case reports and small series, it has been highly successful in controlling uterine bleeding from atony when other methods have failed.38

— Chapter Q: Cesarean Delivery — 15 Figure 1. Anterior uterine wall with B-Lynch stuture in place39 slide 38

A large Mayo needle with #2 chromic catgut is used to enter and exit the uterine cavity anteriorly. The suture is looped over the fundus and then reenters the uterine cavity posteriorly as demonstrated in figures (a) and (b). The suture should be pulled very tight at this point. It is looped back over the fundus, and anchored by entering and exiting the anterior lateral loweruterine segment as shown in figure (a). The free ends of the suture are tied down securely to compress the uterus as shown in figure (c).

Bilateral ligation of the internal iliac arteries (hypogastric arteries) was often used in the past to control uterine hemorrhage by reducing pulse pressure of blood flowing to the uterus. The technique is difficult, especially with a large uterus, a small transverse incision, a pelvis full of blood, and a surgeon who rarely operates in the pelvic retroperitoneal space. A case series of nineteen patient demonstrated that the majority (58 percent) still went on to hysterectomy despite bilateral internal iliac ligation.89 For these reasons, uterine artery ligation and use of compressive uterine sutures has largely replaced this procedure.40

If the hemorrhage continues after atony is resolved and the patient is hemodynamically stable, then placement of one or more No. 30 French Foley catheter with a full 30 cc balloon through the cervix into the uterine cavity may tamponade the bleeding. The Bakri tamponade balloon was specifically designed for uterine tamponade to control postpartum bleeding.41 It is a silicone balloon with a capacity of 500 mL of saline, and strength to withstand a maximum internal and external pressure of 300 mmHg (Figure 2). The balloon is filled until bleeding is controlled.

slide 39 Figure 2. Bakri Balloon Catheter42

A) The Bakri balloon catheter is used for temporary control or reduction of postpartum hemorrhage when conservative management of uterine bleeding is warranted. It is easy to place and rapidly achieves tamponade within the uterine cavity, thereby potentially avoiding a hysterectomy. The tip allows drainage of accumulated blood. B) Under ultrasound guidance, the balloon portion of the catheter is inserted into the uterus, making certain that the entire balloon is inserted past the cervical canal and internal ostium. C) The device is intended for one-time use.

16 — — Chapter Q: Cesarean Delivery These temporizing measures may allow time for correction of reversible conditions such as coagu- slide 43 lopathy or thrombocytopenia. An intravenous fluid bag can be attached to the catheter as it exits the vagina to provide traction. Another modality to stop uterine bleeding is selective arterial embolization. If these efforts fail, a hysterectomy may be necessary. In the setting of severe postpartum hemorrhage, obstetrical surgeons must balance the maternal risks of attempting to avoid hysterectomy including massive transfusion and even mortality compared to the loss of desired fertility.

Lacerations Lacerations of the uterus are more common with malpresentations, macrosomia, or if the lower uterine segment is very attenuated. If the lower uterine segment is very thin, then laceration can be avoided if the uterine incision is made slightly higher than normal. Other common extensions are into the broad ligament and vagina. To achieve a satisfactory repair, the full extent of the laceration must be exposed and visualized. The first suture should be placed just beyond the apex of laceration. The remaining sutures can be placed in a locked or interrupted fashion. The surgeon should visualize ureteral peristalsis throughout its course in the broad ligament to assure the uterine repair did not injure the ureter.

Urinary Tract Injury Bladder injury is more common with a Pfannenstiel incision, repeat cesarean delivery, uterine rupture, and cesarean hysterectomy. It is less common with sharp dissection between the lower uterine segment and bladder than with blunt dissection. The ureter is most often injured during efforts to control bleeding from lateral uterine lacerations.

Bladder injury is reported to occur in 0.28 percent (incidence in primary and repeat cesareans: 0.14 and 0.56 percent, respectively) of cesarean deliveries.43 In the same study, ureteral injury occurred in 0.007 percent of all cesarean deliveries,43 compared to a rate of three percent in cesarean hysterectomies.88

The dome of the bladder can be repaired with two-layers of two-zero absorbable suture. If the base or trigone of the bladder is involved, then consultation is suggested. The ureters should be cannu- lated to facilitate their identification during the repair. A urethral catheter should remain in place for five to seven days after cystotomy.

Ureteral injury may go unrecognized, but if suspected, it is necessary to dissect the length of the ureter to assure that ureteral peristalsis is present. Ureteral repair may require consultation from urology, urogynecology or gynecological oncology surgeons. If the ureter is transected, a number eight French ureteral catheter should be thread directly into the ureteral orifice. Another approach is to cannulate the ureter through a cystotomy in the bladder dome. The cystotomy can be closed with two layers of two-zero absorbable suture.

Gastrointestinal Injury Gastrointestinal injuries occur in 0.04 to 0.08 percent cesarean deliveries and are more common when patients have adhesions from prior surgical procedures.44-45 The risk of bowel injury can be minimized by limiting sharp dissection to transparent peritoneum, and lysis of adhesions to sharp dissection with the scissors pointed away from the bowel. Full-thickness defects of less than one centimeter are repaired in a double-layered transverse closure of a longitudinal laceration to avoid

— Chapter Q: Cesarean Delivery — 17 bowel lumen narrowing. The mucosa is repaired with three-zero absorbable suture in an interrupted fashion. The muscular and serosal layers are closed with a three-zero silk suture in an interrupted fashion. Larger or complex lacerations may require consultation and assistance from a general or colorectal surgeon. If fecal contamination of the operative field occurs, then copious irrigation and broad-spectrum antibiotics with gram-negative aerobic and anaerobic coverage are needed. Appropriate antibiotics include: Cefoxitin 1 to 2 grams IV every six hrs; Cefotetan 1 to 2 grams IV every 12 hrs + Gentamicin sulfate (Garamycin®) 1.5 mg/kg every eight hrs.46 If the colon is involved consider adding metronidazole 0.5 to 1 grams IV or ampicillin-sulbactam 3 grams IV to the cephalosporin.46 Prophylactic wound drainage is rarely needed outside the settings of morbid obesity or a ‘wet’ wound. Significant contamination may require secondary closure, especially in obese patients.

Anesthetic complications Despite the advances in anesthesia and increased use of regional anesthesia, the number of deaths due to general anesthesia has not decreased.47 These deaths are frequently attributed to the inability to intubate or ventilate the patient, and are more common when the patient is obese. Other complications are aspiration, inadequate ventilation, respiratory failure, cardiac arrest, local anesthetic toxicity, high spinal/epidural-related hypotension, over dosage, and spinal headache.

Although generally quite safe, these techniques are also associated with various untoward effects. Side effects such as systemic local anesthetic toxicity or spinal headache are caused by technical factors and/or dosing, such as inadvertent intravenous injection or unrecognized dural puncture. Spinal hematoma is a rare complication, and is more likely in patients receiving anticoagulants. Meticulous attention to proper technique reduces the risk of these complications. Should they occur, prompt treatment is indicated.

Other common side effects are caused by known pharmacological effects of the analgesic medications, such as hypotension, pruritus, nausea and vomiting and respiratory depression. Hypotension may be treated by administering a vasopressor. Opioid-induced side effects are optimally managed by administering small doses of an opioid antagonist.

A variety of other side effects have been attributed to regional analgesic techniques, such as long-term backache, effects on the progress and outcome of labor and effects on breastfeeding success. Although an association between regional analgesia and these side effects may exist, a cause-and-effect relationship has not been established. The risk of potential unwanted effects must be weighed against the unparalleled pain relief these techniques provide.

Studies have shown that women who have regional anesthesia have decreased blood loss and less of a post-operative drop in their hematocrit compared to those who have general anesthesia.48

POST-OPERATIVE CARE The care of the post-operative cesarean delivery patient is similar to that provided for any major abdominal surgery. (Table 7)

The wound dressing should be removed in 24 hours and the wound monitored daily. The surgical clips can be removed in three days and tape strips placed for transverse skin incisions. With vertical incisions, clips are removed and tape strips placed at five to seven days. Breast-feeding should be

18 — — Chapter Q: Cesarean Delivery encouraged for all women. The post-operative hemoglobin will determine iron replacement. Discharge can usually be accomplished in two to four days with a gradual return to full activity based on patient comfort. Fertility planning should be discussed prior to discharge and again at the six-week visit. slides 40-41 Table 7. Postoperative Orders

1. Vital signs and fundal status every hour X four, every four hours X 24, then every eight hours. 2. Massage uterus per schedule above; report extra lochia. 3. Intake and output every four hours X 24. 4. Activity ad lib, encourage ambulation TID. 5. Cough, deep breathing, and incentive spirometry every one hour when awake. 6. Foley to closed drainage, discontinue catheter first post-operative morning, or when ambulating well. 7. Diet as tolerated after nausea resolved. 8. D5 lactated ringers with 20 units of oxytocin (Pitocin®) / liter at 125 cc/hr times two bags, then D5 lactated ringers @ 125 cc/hr. Convert to heparin lock when tolerating oral well. 9. Morphine sulfate two to eight mg intravenously every two hours as needed for pain. 10. Droperidol (Inapsine®) 1.25 to 5.0 mg every four hours intravenously, PRN nausea (or promethazine (Phenergan®) 25 to 50 mg every four hours intramuscularly PRN). 11. Oxycodone and acetaminophen (Percocet®) one to two every three to four hours, PRN, after tolerating oral intake. 12. Lab: first post-operative AM — hemoglobin/hematocrit. 13. Administer Rhogam® if indicated by infant cord blood Rh status. 14. Administer rubella, hepatitis, and Dtap vaccines at discharge if indicated.

Post-Operative Patient Instructions slides 42-43 Post-cesarean delivery patient instructions are similar to any major GYN or abdominal surgery. • Call the office for any problems, including increased abdominal pain, fever, or vaginal discharge. • The abdominal wound should be kept dry and is best treated with minimal dressing. The area can be cleansed with warm water and mild soap. The patient should notify their provider if they notice redness or increased warmth, drainage, feel fluid under the skin, or for temperature greater than 100.5º F, or 38º C. • If the patient has unanswered questions after the cesarean, then the patient should discuss them with their physician or case manager. An unhurried conversation with their doctor, when they are feeling well, will go a long way toward resolving questions the patient may have. • Patients should be educated about the risks of vertical uterine incisions versus low-transverse incisions for future pregnancies. In our increasingly mobile society, it is reasonable to provide the patient with a copy of her operative report for presentation to her clinician during a subsequent pregnancy.

Recommendations for activity after obstetric and gynecologic procedures remain based on tradi- tion and anecdote. The available data do not support many of the recommendations currently provided.49 Restrictions on lifting and climbing stairs should likely be abandoned. Guidance on driving should focus on the concern regarding cognitive function and analgesics rather than concerns of wound separation/dehiscence. Given the impact of these recommendations on daily life events, consistent, evidence-based advice on when and how women can safely resume exercise, driving, working, and sexual intercourse is critical. (Table 8)

— Chapter Q: Cesarean Delivery — 19 Table 8. Evidence Supporting Advice Advice Evidence Our Recommendations Future Research Lifting Lifting increases • Patients should continue lifting • Prospective cohort study intraabdominal pres- patterns as before surgery of patients encouraged to sure much less than • Patients need an adequate post- resume regular exercise Valsalva, forceful op analagesic regimen program coughing, or rising • Pre and post recommendations • Trial in which women are from supine to erect should be consistent randomly assigned to lift position weights lighter than before surgery or lift the same amount of weights

Climbing Climbing stairs • Patients should continue climbing • Prospective cohort study stairs increases intraabdomi- stairs as before surgery of patients encouraged to nal pressure much • Patients need an adequate resume regular exercise less than Valsalva, postop analgesic regimen program, including climbing forceful coughing or • Pre and post recommendations stairs rising from supine to should be consistent erect position

Driving No retrospective or • Patients need an appropriate • Prospective cohort study prospective evidence postop analgesic regimen that of women encouraged to does not cause a clouded senso- resume normal activities, rium when driving including driving • Patients may resume driving when comfortable with hand and foot movements required for driving • Pre and postop recommendations should be consistent

Exercise Limited retrospec- • Patients need an appropriate • Prospective interventional tive and prospective postop analgesic regimen studies to encourage evidence. Forceful • Patients may resume preop exer- women to resume exercise coughing increases cise level programs, as well as build intraabdominal pres- • Exercise program may need to be strength and cardiovascular sure as much as jump- tailored for postpartum women health ing jacks • Pre and postop recommendations should be consistent

Vaginal No consistent retro- • Women and their partners should • Prospective interventional intercourse spective evidence; no make the decision to resume studies aimed to help prospective evidence intercourse mutually women resume sexual • Women should use vaginal lubri- intimacy after gynecologic cants and sexual positions permit- surgery; such studies should ting the woman to control the capture data on incidence of depth of vaginal penetration vaginal valt dehiscence and • Women should use appropriate its associated factors contraception after childbirth • Pre and postop recommendations should be consistent

Returning No consistent pro- • Women should be encouraged • Prospective studies evaluat- to work spective or retrospec- to return to work relatively soon ing the optimal strategies to tive evidence postop permit women to return to • Consider graded return to work effective work • Pre and postop recommendations should be consistent

Reprinted from Obstet Gynecol, 2009 Oct;114(4):892-900, Minig L, Trimble EL, Sarsotti C, Sebastiani MM, Spong CY, Building the evidence base for postoperative and postpartum advice, with permission from Wolters Kluwer Health 2011.

20 — — Chapter Q: Cesarean Delivery slide 44 EARLY POST-OPERATIVE COMPLICATIONS The most common early complications after cesarean delivery are infectious. The rate of infection without prophylactic antibiotic approaches 85 percent, while the infection rate with prophylactic antibiotics is only about five percent. Hence, routine antibiotic therapy is more than “prophylactic.” A single dose of a first generation cephalosporin or ampicillin is as effective as other regimens, including multiple doses or lavage techniques.8-9 Atelectasis is a common source of fever and can lead to pneumonitis. Septic shock, pelvic abscess, and septic thrombophlebitis occur in less than two percent of cases.

Endomyometritis Endomyometritis is a clinical diagnosis that presents with uterine or parametrial tenderness, fever (two postoperative temperatures over 38º C beyond 24 hours), and leukocytosis. The leukocyte count is normally elevated in labor and the early puerperium, averaging 14,000 to 16,000 per mil- limeter and may not help in distinguishing an infectious etiology. Cultures of the lochia are often misleading. Blood cultures are frequently negative. Ninety percent of cases will resolve within 72 hours with broad-spectrum intravenous antibiotics. A small percentage of patients will develop septic thrombophlebitis, parametrial phlegmon, pelvic abscess, and peritonitis.

Wound Separation/Infection Wound separation or opening is a common surgical complication after cesarean delivery, occurring in approximately five percent of cases. Of those wounds that open, nearly two-thirds are infected.50

Wound infection presents with erythema and tenderness, and may develop purulence and fever. Wound infection is a clinical diagnosis with laboratory data serving as an adjunct. The leukocytosis is variable and wound cultures are often misleading. Ultrasound of the abdominal wall may be helpful to localize an abscess. Treatment includes broad-spectrum antibiotics and vigorous wound care. The wound may need to be probed, opened, irrigated, and packed, and necrotic tissue debrided. The patient and caregiver should be instructed about ongoing home care. The decision about delayed secondary closure versus healing by secondary intention will be influenced by the size of the wound and the logistics of follow-up care.

Fascial dehiscence occurs in approximately six percent of open wounds.50 Fascial dehiscence presents with copious discharge followed by protrusion of bowel through the surgical wound. If this occurs, the bowel should be covered with a moist sterile gauze pad and consultation obtained immediately. The wound should be explored, cleansed, debrided, and closed with retention sutures or a mass closure (e.g., Smead-Jones closure), using long-term absorbable suture.

Urinary Tract Infection Urinary tract infections are often associated with use of an indwelling urethral catheter. Treatment should be initiated with broad-spectrum antibiotics, and subsequent antibiotic therapy based on urine culture and sensitivity results.

Gastrointestinal Complications An ileus presents with abdominal distention, nausea, vomiting, and failure to pass flatus. Physical exam may reveal the absence of bowel sounds. Radiographic studies show distended loops of small and large bowel, with gas usually present in the colon. Treatment involves withholding oral intake, awaiting the return of bowel function, and providing adequate fluids and electrolytes.

— Chapter Q: Cesarean Delivery — 21 In contrast, obstruction has high-pitched bowel sounds and peristaltic rushes. Radiographic studies show single or multiple loops of distended bowel, usually in the small bowel, with air fluid levels. The patient may need nasogastric suctioning, or a duodenal/jejunal tube. Surgical consultation and possible lysis of adhesions may be needed if an obstruction persists.

Thromboembolic Complications Deep venous thrombosis (DVT) is three to five times more common after cesarean delivery than vaginal delivery. DVT can progress to pulmonary embolus if untreated. DVT typically presents with leg tenderness, swelling, a palpable cord, or a positive Lowenberg test. (See Chapter B. Medical Complications)

The American College of Chest Physicians practice guidelines recommend early mobilization in postpartum women with no risk factors for DVT other than the postpartum state and the operative delivery.51 For women with at least one additional risk factor, they suggest pharmacologic thromboprophylaxis (prophylactic low molecular weight heparin or unfractionated heparin) or mechanical prophylaxis while the patient is in the hospital. . For women with multiple risk factors for thromboembolism, they suggest pharmacologic thromboprophylaxis combined with graduated compression stocking and/or intermittent pneumatic compression. Marik and Plante (see table 9) developed a risk stratification approach to VTE prophylaxis.52

Table 9. Risk Assessment for Thromboembolism in Patients Who Undergo Cesarean Section*

Low Risk: early ambulation – Cesarean delivery for uncomplicated pregnancy with no other risk factors Moderate risk: low-molecular-weight heparin or compression stockings – Age > 35 yr – Obesity (BMI > 30) – Parity > 3 – Gross varicose veins – Current infection – Preeclampsia – Immobility for > four days before operation – Major current illness – Emergency cesarean section during labor High risk: low-molecular-weight heparin and compression stockings – Presence of more than two risk factors from the moderate risk section – Cesarean hysterectomy – Previous deep-vein thrombosis or known thrombophilia

*BMI denotes body-mass index (the weight in kilograms divided by the square of the height in meters).

22 — — Chapter Q: Cesarean Delivery Septic Thrombophlebitis Septic thrombophlebitis is a diagnosis of exclusion. Persistent and unexplained fever is often the only symptom of septic thrombophlebitis, though some patients complain of pelvic pain. Physical examination, ultrasound, and computerized tomography are frequently negative. Continued fever without a known origin despite several days of antibiotic therapy suggests septic thrombophlebitis. Defervescence on heparin therapy provides effective treatment and confirms the diagnosis.

DELAYED POST-OPERATIVE COMPLICATIONS slide 45 Uterine Dehiscence and/or Rupture Dehiscence and rupture of a uterine scar are uncommon complications that are diagnosed during a subsequent pregnancy. They are discussed in detail in the section on Trial of Labor after Cesarean below.

Placenta Accreta There is a significant increased risk of placenta previa, placenta accreta, placenta previa with accreta, and the need for gravid hysterectomy after a woman’s second cesarean delivery.53 One in four patients who undergoes repeat cesarean delivery because of placenta previa will require cesarean hysterectomy for hemorrhage caused by placenta accreta. This complication increases with the number of prior uterine incisions.54 In focal placenta accreta, the placental bed can be curetted and over sewn with interrupted sutures placed around the area of hemorrhage. If not successful, then complete hysterectomy may be necessary, because supracervical hysterectomy may not control the hemorrhage.

Repeat Cesarean Delivery A major complication of cesarean delivery is that nearly two thirds of patients will undergo cesarean delivery with subsequent pregnancies. Repeated surgeries may also involve adhesions and subfer- tility, chronic pain syndromes and keloid formation.

Cesarean Hysterectomy Indications for cesarean hysterectomy are uterine hemorrhage unresponsive to treatment, uterine laceration that would result in an unstable repair, placenta accreta, laceration of major pelvic vessels, large myomas, and advanced cervical dysplasia or carcinoma. Complications of cesarean hysterectomy are more common during emergent procedures and include increased blood loss and anesthesia time, plus infection, blood transfusion, and unanticipated sterility.

CONTROVERSIES slide 46 Electronic Fetal Monitoring The widespread use of electronic fetal monitoring (EFM) and the increased rate of cesarean delivery in response to fetal heart patterns detected with EFM have neither decreased acidosis-related newborn morbidity, nor decreased the incidence of cerebral palsy. (See Chapter E. Intrapartum Fetal Surveillance)

Breech Presentation The American College of Obstetricians and Gynecologists recommends that the decision regarding mode of delivery should depend on the experience of the health care provider Cesarean delivery will be the preferred mode for most physicians because of the diminishing expertise in vaginal breech delivery.55 Planned vaginal delivery of a term singleton breech fetus may be reasonable under hospital-

— Chapter Q: Cesarean Delivery — 23 specific protocol guidelines56 for both eligibility and labor management. Before a vaginal breech delivery is planned, women should be informed that the risk of perinatal or neonatal mortality or short-term serious neonatal morbidity may be higher than if a cesarean delivery is planned,57 and the patient’s informed consent should be documented.55

Women with a breech presentation at 37 weeks should be encouraged to undergo external cephalic version if they do not have a contraindication. When VBAC or vaginal breech delivery are not offered by either the patient’s provider or planned hospital, referral to a provider and/or facility that does offer these should be investigated.58 Planned cesarean delivery compared with planned vaginal birth reduced perinatal or neonatal death or serious neonatal morbidity, at the expense of somewhat increased maternal morbidity.59 (See Chapter G. Malpresentations)

Incidental Procedures Some clinicians choose to perform a cesarean delivery on patients near term if the patient has another indication for surgery, e.g., desires sterilization. Several simple methods that result in tubal occlusion are available. Performance of an elective cesarean delivery because of the second surgical procedure should be discouraged because of the increased morbidity and hospital stay.

The surgeon’s primary responsibility is safe operative delivery, even when pathology is found. Removal of adnexal abnormalities should be reserved for obvious malignancy, or lesions susceptible to torsion. Most leiomyomas regress after pregnancy and are highly vascular, hence removal should not be attempted unless an accessible pedicle and torsion is anticipated. Such lesions should be cross-clamped and Heaney transfixion ligated with an absorbable suture. A woman’s lifetime risk for acute appendicitis is approximately 10 percent at age 17, but falls to only 3.5 percent by age 37. Thus, routine elective removal of the appendix at the time of cesarean delivery is not indicated.

Macrosomia Although the diagnosis of fetal macrosomia is imprecise, prophylactic cesarean delivery may be considered for suspected fetal macrosomia with estimated fetal weights greater than 5,000 g in women without diabetes and greater than 4,500 g in women with diabetes.60 A review of the available literature on the sonographic detection of macrosomia (> 4000 g) in general obstetrical populations reported widely varying results: sensitivity 12 to 75 percent, specificity 68 to 99 percent, and posttest probability after a positive test 17 to 79 percent; results for populations with a high prevalence of macrosomia were at the upper end of these ranges.61 The diagnosis of macrosomia defined as > 4500 was even less accurate, and there were no data on the ability to identify fetuses > 5000 g. Hence 3,695 cesarean deliveries would have to be performed at an additional cost of $8.7 million, to prevent one permanent brachial plexus injury in fetuses over 4,500 gram in mothers without diabetes.62 Most brachial plexus injuries resolve spontaneously, and can occur in fetuses weighing less than 4,000 grams born by cesarean delivery. The results of the single randomized controlled trial comparing elective delivery with expectant management at term in pregnant women with insulin-requiring diabetes show that induction of labor reduces the risk of macrosomia.63 Induction of labor for suspected fetal macrosomia in non-diabetic women has not been shown to alter the risk of maternal or neonatal morbidity.64

24 — — Chapter Q: Cesarean Delivery Litigation Concerns over liability risk have a major impact on the willingness of physicians and health care institutions to offer trial of labor.6 These concerns derive from the perception that catastrophic events associated with trial of labor could lead to compensable claims with large verdicts or settle- ments for fetal/maternal injury—regardless of the adequacy of informed consent. Clearly, these medical malpractice issues affect practice patterns among health care providers and they played a role in the genesis of the College’s 1999 “immediately available” guideline.

Studies have attempted to model the impact of tort reform on primary and repeat cesarean delivery rates and have shown that modest improvements in the medical-legal climate may result in increases in VBAC and reductions in cesarean deliveries.6 These analyses suggest that both caps on noneconomic damages and reductions in physician malpractice premiums would result in fewer cesarean deliveries.

Many health care providers incorrectly assume that performing a cesarean delivery helps avoid malpractice litigation. Performance of a cesarean offers no protection against allegations of malpractice if a less-than perfect infant is born. The plaintiff’s legal team may shift to other issues, such as the cesarean delivery not being performed sooner, or a perceived lack of antenatal testing or prenatal care.

PERIMORTEM HYSTEROTOMY (CESAREAN DELIVERY) slides 47-49 Cesarean delivery has come full circle from its ancient origins as a postmortem procedure to bury mother and infant separately, to the current recommendation that all appropriately skilled physicians should be able to perform a perimortem cesarean delivery that could save two lives.65 The American Heart Association has recommended perimortem cesarean delivery in pregnant women who have not responded to resuscitative efforts since the 1990s.66 Uterine evacuation can increase cardiac output by 25 percent by relief of aortocaval compression. If promptly performed, perimortem cesarean delivery improves infant and maternal survival. The best survival rates are obtained when perimortem cesarean delivery is performed within five minutes of ineffective maternal circulation. It is still worthwhile to pursue delivery after five minutes, however, because fetal mortality is 100 percent if no action is taken. It is not necessary to obtain consent from family members before performing the procedure. (See Chapter K. Maternal Resuscitation).

Emergency hysterotomy is indicated when: • Personnel with appropriate skill and equipment to perform the procedure are involved, • The mother fails to respond with a return of spontaneous circulation within four minutes, • Singleton gestation of 20 weeks or greater, and • Appropriate facilities and personnel are available to care for the mother and infant after the procedure.

TRIAL OF LABOR AFTER CESAREAN (TOLAC) slides 50-52 Counseling regarding cesarean delivery should occur during the prenatal care of all women. Most nulliparous women have a strong preference for spontaneous vaginal delivery and will be interested in ways in which they can decrease the likelihood of requiring a cesarean in labor.58

— Chapter Q: Cesarean Delivery — 25 The decision by a pregnant woman to attempt a TOLAC or a planned repeat cesarean delivery involves a balancing of maternal and neonatal risks for each woman, as well as personal preference. The rate of perinatal mortality associated with TOLAC is similar to the perinatal mortality rate for infants born to nulliparous women in labor, 1.3/1000 births compared to 0.5/1000 births in women choosing repeat cesarean delivery.67

During the informed consent process at least three basic issues need to be addressed: • What is the patient’s plan for future family size? • What is the chance of a successful vaginal birth after cesarean? • What are the safety concerns?

FUTURE FAMILY SIZE Although there is no difference between planned cesarean delivery and planned vaginal delivery in risk of peripartum hysterectomy in a woman’s first delivery, there is a significant increased risk of placenta previa, placenta accreta, placenta previa with accreta, and the need for gravid hysterectomy after a woman’s second cesarean delivery.53 This emphasizes the need to consider the mother’s total number of planned or expected pregnancies if cesarean delivery on maternal request is discussed during her first pregnancy, realizing that many pregnancies are unplanned.69 These are also factors that may be influenced by parity and planned family size. Uterine scars put women at increased risk for uterine rupture in subsequent pregnancies.67, 70

For those considering larger families, VBAC may avoid potential future maternal consequences of multiple cesarean deliveries69 such as hysterectomy, bowel or bladder injury, transfusion, infection,53, 71 and abnormal placentation such as placenta previa and placenta accrete.53-54

CHANCE FOR SUCCESSFUL VAGINAL BIRTH Most women with one previous cesarean delivery with a low-transverse incision are candidates for and should be counseled about VBAC and offered TOLAC.69

Approximately 75 percent of women who attempt TOLAC will be successful; this rate varies up or down depending upon the clinical situation that led to the first cesarean birth.6 VBAC is highest in women with a previous successful TOLAC, previous vaginal delivery, previous cesarean delivery for nonvertex presentation, and women with spontaneous onset of labor. (see Figure 1)

The studies of women with twin gestations who attempt VBAC have consistently demonstrated that their outcomes are similar to those of women with singleton gestations who attempt VBAC with regard to likelihood of success and risk of uterine rupture or maternal or perinatal morbidity complications.72-73 Women with one previous low transverse cesarean delivery, who are otherwise appropriate candidates for twin vaginal delivery, may be considered candidates for TOLAC.69

26 — — Chapter Q: Cesarean Delivery Figure 1. Factors that impact the success of a trial of labor after cesarean delivery slides 53-55 Decreased success (< 60 percent) – Two or more prior cesarean deliveries without a vaginal delivery – Cesarean delivery for failure to descend in second stage – Labor induction required – Infant 4000 g or more – Body mass index (BMI) greater than 40 kg/m2 – Maternal age older than 35 years

Neutral success (65 percent to 75 percent) – Gestational age older than 40 weeks – Prior cesarean delivery for nonreassuring fetal monitoring – Unknown scar – Twins (limited data) – Labor augmentation – Two prior cesarean deliveries with history of vaginal birth (limited data) – Cesarean delivery for failure to progress in first stage of labor – BMI 25 to 40 kg/m2

Increased success (> 75 percent) – Prior successful vaginal birth – BMI 25 kg/m2 or less – Prior cesarean delivery for breech presentation – Spontaneous labor with ripe cervix by Bishop score – Maternal age younger than 35 years

Percentages are estimates of the influence of a single factor’s influence on the success of a trial of labor. Because patients rarely present with only one of these issues, providers must try to balance the impact of a series of influences to individually guide patients in their decision to attempt trial of labor as the delivery plan. Note that even in the presence of factors that have a negative impact, most women attempting a trial of labor after cesarean will be successful.

Although there is no universally agreed on discriminatory point,69 evidence suggests that women with at least a 60 to 70 percent chance of VBAC have equal or less maternal morbidity when they undergo TOLAC than women undergoing elective repeat cesarean delivery.74–75 Conversely, women who have a lower than 60 percent probability of VBAC have a greater chance of morbidity than women undergoing repeat cesarean delivery. Similarly, because neonatal morbidity is higher in the setting of a failed TOLAC than in VBAC, women with higher chances of achieving VBAC have lower risks of neonatal morbidity. One study demonstrated that composite neonatal morbidity is similar between TOLAC and elective repeat cesarean delivery for the women with the greatest probability of achieving VBAC.75

SAFETY CONCERNS Women with previous cesarean delivery have two options for delivery during subsequent pregnancies; they may have an elective repeat cesarean delivery or they may undergo a trial of labor after cesarean (TOLAC). Sixty to 80 percent of women with previous cesarean delivery

— Chapter Q: Cesarean Delivery — 27 can experience a successful vaginal delivery with a prior cesarean delivery.67 The benefit of this is decreased maternal risk associated with vaginal delivery (decreased blood loss and risk of transfusion, decreased risk of thromboembolism, and decreased risk of infection) and a quicker recovery period with decreased length of hospitalization. (See Appendix 1)

Planned elective repeat caesarean delivery and planned vaginal birth after cesarean delivery for women with a prior caesarean birth are both associated with benefits and harms. The two major risks of TOLAC are uterine dehiscence and/or rupture. Due to the risk of uterine rupture fetal death has been shown to increase with TOLAC versus repeat elective cesarean delivery. Evidence for the risks and benefits of TOALC vs repeat cesarean are predominantly from retrospective cohort studies due to the inability to conduct randomized controlled trials.76

Uterine Dehiscence and/or Rupture Dehiscence and rupture of a uterine scar are uncommon complications that are diagnosed during a subsequent pregnancy. The overall rate of uterine rupture during a subsequent TOLAC is 0.7 percent.70, 77 (See Figure 2)

Symptomatic uterine rupture occurs in 0 to 7.8 per 1000 TOLACs (pooled weighted mean 3.16 per 1000 TOLACs).67, 70 On average, the incremental risk of rupture with TOLAC compared with elective repeat cesarean delivery (ERCD) is 2.7 per 1000.

The term uterine dehiscence is commonly applied to asymptomatic scar separation that does not penetrate the serosa and does not produce hemorrhage. Dehiscence occurs in 0 to 19 per 1000 TOLACs (mean weighted average 12.6 per 1000 TOLACs). This rate is comparable to that in women undergoing ERCD.67 Dehiscence presents as a “serosal window” and is often discovered unexpectedly during a repeat cesarean delivery. (Box 2) Rupture of lower segment scars usually occurs during labor, but may occur antepartum, particularly with classical uterine scars.78

RUPTURE In contrast to dehiscence, uterine rupture is a through-and-through scar separation that is clinically symptomatic and requires surgical intervention. Uterine rupture occurs in about 0.7 percent of women with a prior cesarean delivery.70, 77

Fetal bradycardia is the most common and characteristic clinical manifestation of uterine rupture, occurring in 33 to 70 percent of symptomatic cases.79 Variable or late decelerations may precede the bradycardia, but there is no fetal heart rate pattern pathognomonic of rupture. Perinatal mortality/morbidity is higher in fetuses that experience complete extrusion into the maternal abdomen than in those who are not extruded.80

Maternal manifestations are variable. In women with known uterine scarring or trauma, uterine rupture should always be strongly considered if constant abdominal pain and signs of intraabdominal hemorrhage are present. Vaginal bleeding is not a cardinal symptom, as it may be modest, despite major intraabdominal hemorrhage. Other clinical manifestations include maternal tachycardia, hypotension ranging from subtle to severe (hypovolemic shock), cessation of uterine contractions, loss of station of the fetal presenting part, uterine tenderness, and change in uterine shape.

28 — — Chapter Q: Cesarean Delivery Postpartum, uterine rupture is characterized by pain and persistent vaginal bleeding despite use of uterotonic agents. Hematuria may occur if the rupture extends into the bladder.

Treatment of symptomatic uterine rupture is largely dependent on the patient’s hemodynamic status and desire for future fertility. In some cases, a layered closure of the myometrium with absorbable suture will suffice, though hysterectomy may be necessary.

PREVIOUS UTERINE INCISION The preponderance of evidence suggests that most women with one previous cesarean delivery with a low transverse incision are candidates for and should be counseled about VBAC and offered TOLAC.

A 2006 study with sufficient size to control for confounding variables found no increased risk of uterine rupture (0.9 percent versus 0.7 percent) in women with one versus multiple prior cesarean deliveries.81 Additionally, the chance of achieving VBAC appears to be similar for women with one or more than one cesarean delivery. Given the overall data, it is reasonable to consider women with two previous low transverse cesarean deliveries to be candidates for TOLAC, and to counsel them based on the combination of other factors that affect their probability of achieving a successful VBAC.69

Those at high risk for complications (e.g., those with previous classical or T-incision, prior uterine rupture, or extensive transfundal uterine surgery) and those in whom vaginal delivery is otherwise contraindicated (e.g., those with placenta previa) are not generally candidates for planned TOLAC.69

INDUCTION LABOR Induction of labor for maternal or fetal indications remains an option in women undergoing TOLAC.69 Studies of specific prostaglandins are limited in size, but indicate that rupture risk may vary among these agents. Given the lack of compelling data suggesting increased risk with mechanical dilation and transcervical catheters, such interventions may be an option for TOLAC candidates with an unfavorable cervix.69

Evidence from small studies show that the use of misoprostol (prostaglandin E1) in women who have had cesarean deliveries is associated with an increased risk of uterine rupture.82 Therefore, misoprostol should not be used for third trimester cervical ripening or labor induction in patients who have had a cesarean delivery or major uterine surgery.69

REGIONAL ANALGESIA Epidural analgesia for labor may be used as part of TOLAC, and adequate pain relief may encourage more women to choose TOLAC.69, 83 No high quality evidence suggests that epidural analgesia is a causal risk factor for an unsuccessful TOLAC.84 In addition, effective regional analgesia should not be expected to mask signs and symptoms of uterine rupture, particularly because the most common sign of rupture is fetal heart tracing abnormalities.

EXTERNAL CEPHALIC VERSION Limited data regarding external cephalic version for breech presentation in a woman with a prior uterine incision suggest that external cephalic version is not contraindicated if a woman is at low risk of adverse maternal or neonatal outcomes from external cephalic version and TOLAC.85 The chances of successful external version have been reported to be similar in women with and without a prior cesarean delivery.69

— Chapter Q: Cesarean Delivery — 29 UNKNOWN TYPE OF PREVIOUS UTERINE INCISION The type of uterine incision performed at the time of a prior cesarean delivery cannot be confirmed in some patients. Although some have questioned the safety of offering VBAC under these circumstances, two case series, both from large tertiary care facilities, reported rates of VBAC success and uterine rupture similar to those from other contemporaneous studies of women with documented previous low transverse uterine incisions.86 No significant association was found with the presence of an unknown scar when evaluating risk factors for uterine rupture. The absence of an association may result from the fact that most cesarean incisions are low transverse, and the uterine scar type can often be inferred based on the indication for the prior cesarean delivery. Therefore, TOLAC is not contraindicated for women with one previous cesarean delivery with an unknown uterine scar type unless there is a high clinical suspicion of a previous classical uterine incision.69

Figure 2. Factors influencing risk for uterine rupture slides 56-58 Decreased success (< one percent) – Prior vaginal delivery – Low uterine segment incision from prior cesarean – Preterm delivery – Two-layer closure of uterine incision

Neutral success (one to two percent) – Induction of labor with good Bishop score with oxytocin – One-layer uterine closure – Gestational age of more than 40 weeks – Low vertical uterine incision (limited data; could be increased to up to five percent) – Unknown uterine scar without high risk for prior classical incision

Increased success (less than two to four percent) – Unknown scar in the setting of high risk for prior classical incision (e.g., preterm abnormal lie or term transverse lie) – Classical or T uterine incision (four to nine percent) – Prior, myomectomy, cornual resection, or other full-thickness uterine surgery – Prior uterine rupture – Morbid obesity (BMI > 40 kg/m2) – Two or more prior uterine incisions without vaginal delivery – Induction of labor with poor Bishop score with prostaglandin agent or oxytocin

Percentages are estimates of the influence of a single factor’s influence on the likelihood of uterine rupture. Because patients rarely present with only one of these factors and evidence is limited on the additivity of multiple factors, physicians or midwives must try to assess the impact of a series of influences to provide individualized guidance to a patient during prenatal care.

LEVEL OF CARE After consideration of the NIH Consensus Development Conference on Vaginal Birth After Cesarean data ACOG stated that a trial of labor after previous cesarean delivery should be undertaken at facilities capable of emergency deliveries.69

30 — — Chapter Q: Cesarean Delivery “Because of the risks associated with TOLAC and that uterine rupture and other complications may be unpredictable, the College recommends that TOLAC be undertaken in facilities with staff immediately available to provide emergency care. When resources for immediate cesarean delivery are not available, the College recommends that health care providers and patients considering TOLAC discuss the hospital’s resources and availability of obstetric, pediatric, anesthetic, and operating room staffs. Respect for patient autonomy supports that patients should be allowed to accept increased levels of risk, however, patients should be clearly informed of such potential increase in risk and management alternatives.”69

Furthermore ACOG stated that after counseling, the ultimate decision to undergo TOLAC or a repeat cesarean delivery should be made by the patient in consultation with her health care provider.69 The potential risks and benefits of both TOLAC and elective repeat cesarean delivery should be discussed. Documentation of counseling and the management plan should be included in the medical record.

The Northern New England Perinatal Quality Improvement Network (NNEPQIN) VBAC Guidelines has offered a three tiered risk based system with management suggestions87 (Table 10). This system would need to be modified for individual facilities, level of resources, and as new data emerges.

Table 10. Patient Condition/Complications Management Approach Classification Low risk - One prior low transverse cesarean - No additional interventions other than those delivery listed above. - Spontaneous onset labor - Cesarean delivery provider may have other - No need for augmentation acute patient care responsibilities. - No repetitive FHR abnormalities - Patients with a prior successful VBAC are especially low risk. However, their risk status escalates the same as other low risk patients.

Medium risk - Induction of labor - Cesarean delivery provider in the hospital dur- - Pitocin augmentation ing the active phase of labor. Cesarean delivery - Two or more prior low transverse provider may have other acute patient care cesarean deliveries responsibilities. - < 18 months between prior cesarean - An open and staffed operating room is available delivery and current delivery. or there is a plan in place if immediate delivery is required. This may be a room where there is adequate lighting, instruments, and general anesthesia can be administered if needed. - An anesthesia provider is present in the hospital during the active phase of labor. - Anesthesia staff may have other acute patient care responsibilities. - There is an established back up protocol for anesthesia services during busy times.

High risk - Repetitive non-reassuring FHR abnor- - The cesarean delivery provider is present in the malities not responsive to clinical hospital and does not have other acute patient intervention. care responsibilities - Bleeding suggestive of abruption - Anesthesia staff is present and does not have - Two hours without cervical change in other acute patient care responsibilities. the active phase despite adequate labor - An open and staffed operating room is available.

— Chapter Q: Cesarean Delivery — 31 SUMMARY Cesarean delivery is the most common operative procedure in the US and has accounted for nearly one third of all deliveries. Cesarean delivery can involve significant morbidity and mortality, both of which can be minimized by thoughtful patient selection, pre-operative, intra-operative and post-operative care. All maternity care providers should be familiar with the diagnosis and management or slide 59 post-cesarean complications. Efforts to lower the primary cesarean rate and increase access to trial of labor after cesarean are of public health importance due to the increased morbidity and mortality of repeat cesarean delivery.

The application of evidence-based practice to cesarean delivery and support for patient safety in the operating room and postpartum settings can decrease operative morbidity.

SUMMARY OF TABLE RECOMMENDATIONS Category A The Joel-Cohen–based techniques have advantages over Pfannenstiel and traditional cesarean techniques in relation to short-term outcomes. There is no evidence in relation to long-term outcomes.14 No preoperative hair removal; or clipping or depilatory creams on the day of surgery or the preceding day (no shaving).14 No specific antiseptic for preoperative bathing.14 Suture closure of subcutaneous fat results in a decreased risk of wound disruption with fat thickness greater than 2 cm.29-30 Subcuticular sutures, interrupted sutures, staples, or tissue adhesive skin closure are acceptable.31-34 No withholding of oral fluids after surgery.35

Category B Antibiotic prophylaxis with a single dose of ampicillin or a first-generation cephalosporin9 prior to skin incision at cesarean delivery.10-11 Double gloving is advised in areas with high rates of blood-borne infections to achieve fewer perforations in inner glove and prevent needle stick injuries.14 Transverse lower abdominal wall opening and uterine opening using Joel-Cohen–based methods.15 Bladder peritoneum may be reflected downward or not.17 Spontaneous placental removal with cord traction reduces blood loss.22 Either intraabdominal or extraabdominal repair of the uterus are acceptable.24 Nonclosure of both peritoneal layers.28 No routine drainage of the subcutaneous tissues.36 Most women with one previous cesarean delivery with a low-transverse incision are candidates for and should be counseled about VBAC and offered TOLAC.69, 77 Epidural analgesia for labor may be used as part of TOLAC.69, 84 Women with two previous low transverse cesarean deliveries may be considered candidates for TOLAC.69, 81 Women with one low transverse incision, who are otherwise appropriate candidates for twin vaginal delivery, may be considered candidates for TOLAC.69, 72, 73

32 — — Chapter Q: Cesarean Delivery External cephalic version for breech presentation is not contraindicated in women with a prior low transverse uterine incision who are at low risk for adverse maternal or neonatal outcomes from external cephalic version and TOLAC.69, 85 TOLAC is not contraindicated for women with previous cesarean delivery with an unknown uterine scar type unless there is a high clinical suspicion of a previous classical uterine incision.69, 86

Category C Uterine closure with interrupted or single-layer continuous locking suture has short-term benefits. However, the evidence from observational studies of an increased risk of scar rupture may favor the use of double-layer closure pending evidence on this outcome from randomized trials.14, 26-27 Misoprostol should not be used for third trimester cervical ripening or labor induction in patients who have had a cesarean delivery or major uterine surgery.69, 82 Those at high risk for complications (e.g., those with previous classical or T-incision, prior uterine rupture, or extensive transfundal uterine surgery) and those in whom vaginal delivery is otherwise contraindicated (e.g., those with placenta previa) are not generally candidates for planned TOLAC.69 Induction of labor for maternal or fetal indications remains an option in women undergoing TOLAC.69

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Rouse DJ, Owen J, Goldenberg RL, et al: The effec- Human Development Maternal-Fetal Medicine Units tiveness and cost of elective cesarean delivery for Network. Maternal and perinatal outcomes associated fetal macrosomia diagnosed by ultrasound. JAMA with a trial of labor after prior cesarean delivery. N Engl 1996;276:1480. (Level III) J Med. 2004 Dec 16;351(25):2581-9. Epub 2004 Dec 14. 63. Boulvain M, Stan CM, Irion O. Elective delivery in 78. Halperin ME; Moore DC; Hannah WJ Classical versus diabetic pregnant women. Cochrane Database of low-segment transverse incision for preterm caesar- Systematic Reviews 2009, Issue 2. Art. No.: CD001997. ean section: maternal complications and outcome of DOI: 10.1002/14651858.CD001997. subsequent pregnancies. Br J Obstet Gynaecol 1988 64. Irion O, Boulvain M. Induction of labour for suspected Oct;95(10):990-6. fetal macrosomia. Cochrane Database of Systematic 79. Ridgeway JJ; Weyrich DL; Benedetti TJ Fetal heart Reviews 2009, Issue 2. Art. No.: CD000938. DOI: rate changes associated with uterine rupture. Obstet 10.1002/14651858.CD000938. Gynecol 2004 Mar;103(3):506-12. 65. Katz VL, Dotters DJ, Droegemueller W: Perimortem 80. Leung AS; Leung EK; Paul RH Uterine rupture after cesarean delivery. Obstet Gynecol 1986;68:571. (Level previous cesarean delivery: maternal and fetal conse- III) quences. Am J Obstet Gynecol 1993 Oct;169(4):945-50. 66. American Heart Association Advanced Cardiovascular Life Support Resource Text. 2008

— Chapter Q: Cesarean Delivery — 35 81. Landon MB, Spong CY, Thom E, Hauth JC, Bloom SL, Varner MW, et al. Risk of uterine rupture with a trial of labor in women with multiple and single prior cesarean delivery. National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Obstet Gynecol 2006;108:12–20. slide 10, 11 82. Wing DA, Lovett K, Paul RH. Disruption of prior uterine incision following misoprostol for labor induction in women with previous cesarean delivery. Obstet Gynecol 1998;91:828–30 83. Sakala EP, Kaye S, Murray RD, Munson LJ. Epidural analgesia. Effect on the likelihood of a successful trial of labor after cesarean section. J Reprod Med 1990;35:886–90. 84. Landon MB, Leindecker S, Spong CY, Hauth JC, Bloom S,Varner MW, et al. The MFMU Cesarean Registry: factors affecting the success of trial of labor after previous cesarean delivery. National Institute of Child Health and Human Development Maternal- Fetal Medicine Units Network. Am J Obstet Gynecol 2005;193:1016–23. 85. Clock C, Kurtzman J, White J, Chung JH. Cesarean risk after successful external cephalic version: a matched, retrospective analysis. J Perinatol 2009;29:96–100. 86. Leung AS, Farmer RM, Leung EK, Medearis AL, Paul RH.Risk factors associated with uterine rupture during trial of labor after cesarean delivery: a case-control study. Am J Obstet Gynecol 1993;168:1358–63. 87. Northern New England Perinatal Quality Improvement Network VBAC Guidelines http://www.nnepqin.org/ images/VBAC%20Guideliens%20NNEPQIN%201%20 06%2005.doc (Accessed April 12, 2010) 88. Shelhass CS, Gilbert S, Landon MB, et al. The frequency and complication rates of hysterectomy accompanying cesarean delivery. Obstet Gynecol August 2009, Vol 114 (2) 224-229. 89. Clark SL, Phelan JP, Yeh SY, Bruce SR, Paul RH. Hypogastric artery ligation for obstetric hemorrhage. Obstet Gynecol. 1985 Sep;66(3):353-6 90. Tita ATN, Landon MB, Spong CY, et al. Timing of Elective Repeat Cesarean Delivery and Term and Neonatal Outcomes. N Engl J Med 2009;360:111-20.

36 — — Chapter Q: Cesarean Delivery APPENDIX 1

INFORMATION ABOUT TRIAL OF LABOR AND VAGINAL DELIVERY AFTER CESAREAN DELIVERY Many women in the United States deliver their babies by Cesarean Delivery, an operation where the baby is born through an incision, or cut, in the mother’s abdomen and uterus. For many years doctors believed that if a mother had one cesarean delivery, she must have another cesarean delivery to deliver any other babies. Studies have shown that it is safe for most women who have had a Cesarean delivery in the past to try to have a vaginal birth. This is called a “Trial Of Labor After Cesarean” or TOLAC, and if she is successful she has had a “Vaginal Birth After Cesarean” or VBAC. Although it is safe for most women to try a TOLAC/VBAC there are some women with risk factors that might make it unsafe. Your provider will review your history and records to find out if you would be a good candidate for a TOLAC/VBAC. Many experts encourage mothers who do not have risk factors to attempt a TOLAC/VBAC. At [INSERT YOUR MEDICAL CENTER/HOSPITAL NAME HERE] we feel that it is the best choice for many of our patients. About three out of four women (75 percent) attempting a TOLAC will be successful. There are some advantages and some risks to either having a repeat Cesarean Delivery or a TOLAC/VBAC. There are some risks to both these choices. The decision about whether to try a TOLAC/VBAC is a very personal one. This information sheet provides general facts about repeat Cesarean Delivery and TOLAC/VBAC. Please discuss your personal case with your provider to help you make the right decision for you.

ADVANTAGES TO YOU OF HAVING A TOLAC/VBAC: – Less risk to the mother. Women who have a vaginal birth have less chance of getting an infection. Usually there is less bleeding and less risk of needing a blood transfusion. – Shorter recovery time. Most women can leave the hospital one or two days after a vaginal birth. Most women stay at least two to three days after a Cesarean Delivery. After going home, women who have had a vaginal delivery usually go back to normal activities sooner than those who have had a Cesarean Delivery. There is usually less pain after a vaginal delivery. – More involvement in the birth. Many women feel a vaginal delivery allows them to be more involved in the birth. After a vaginal delivery the mother can usually hold the baby right away and begin breast-feeding. After a Cesarean Delivery, the mother often can’t hold the baby or breastfeed until the operation is over and the mother recovers from anesthesia. More than one family member may be in the room for a vaginal delivery if the patient wishes. Only one person can be in the room for a Cesarean Delivery. If the mother needs general anesthesia (goes to sleep) no one is allowed to be in the operating room. – Future pregnancies. Women who have a successful vaginal birth after cesarean will have less risk of complications with future pregnancies compared to women having a repeat cesarean delivery.

DISADVANTAGES OF A TOLAC: – Unsuccessful labor. Not all women who try to have a vaginal delivery are successful. Mothers who need a repeat Cesarean Delivery after an unsuccessful labor may have more risk of infection, bleeding and blood transfusion or injury to nearby organs such as the bowel and bladder. About three out of four (75 percent) women who try a TOLAC will have a successful VBAC. The chance of a successful VBAC is higher if a woman has had a vaginal delivery in the past.

— Chapter Q: Cesarean Delivery — 37 – Rupture of the uterus. There is a small chance that the scar in the uterus from the previous Cesarean Delivery may rupture, or come apart, in labor. If this happens, an emergency Cesarean Delivery is required. There is a risk that the baby may suffer serious injury or death. At [INSERT YOUR MEDICAL CENTER/ HOSPITAL NAME HERE], there are staff in the hospital 24 hours a day to do an emergency Cesarean Delivery. In most cases the baby is delivered before it is harmed. Rupture of the uterus also increases the risk to the mother of injury to the nearby tissues, such as the bladder or bowel. There is also a risk of needing a hysterectomy. The risk of rupture is higher if you have had more than one Cesarean Delivery in the past and lower if you have had a vaginal delivery in the past.

OTHER ISSUES: – Pain. Many women worry that labor may be painful and that a Cesarean Delivery will mean they don’t have to go through the pain of labor. Although labor is painful, there are many ways to give pain relief. Medicine may be given through an IV and this works for many patients. Epidurals (a procedure that numbs the abdomen so that the patient does not feel labor pains) are available for women who want them. Women who have a Cesarean Delivery usually have more pain for a longer time than women who have a vaginal birth. – Labor induction. The medicine oxytocin (Pitocin) is used to start labor or help it along if it is not progressing normally. Many studies show that Pitocin does not increase the risk of problems for women undergoing TOLAC/VBAC if used to help a labor that has already begun. If Pitocin is used to start labor (induction) the chance of uterine rupture increases from about one in 200 to one in 100 women. At [INSERT YOUR MEDICAL CENTER/HOSPITAL NAME HERE] we use Pitocin in patients trying a TOLAC/VBAC if it is needed. – Monitoring. Patients trying a TOLAC/VBAC at [INSERT YOUR MEDICAL CENTER/HOSPITAL NAME HERE] have continuous monitoring of the baby’s heart rate and uterine contractions. Also an IV will be placed. This helps us to identify problems and do a Cesarean Delivery quickly if necessary.

This information should help you decide if you want a TOLAC/VBAC or a repeat cesarean delivery for the birth of your baby. Please talk to your provider about any questions you have so that you may get the information you need to help make this choice. It may also help to talk to family members. For either decision you make, our goal is to provide you with the best possible care for a good outcome — a healthy mother and healthy baby.

I have read the information sheet and have had the chance to discuss it with my provider. Any questions I had have been answered to my satisfaction.

_____ I choose a trial of labor and vaginal birth after cesarean delivery

_____ I choose to have a repeat cesarean delivery

______Patient (please print) Patient Signature Date

______Provider (please print) Provider Signature Date

______Witness (please print) Witness Signature Date

Adapted from the University of New Mexico Developed by Tony Ogburn, MD and Larry Leeman, MD

38 — — Chapter Q: Cesarean Delivery Chapter R slide 1 Birth Crisis Helen Welch, CNM, MSN Caroline Homer, MScMed, PhD, RM Paul Lewis, MSc, BSc (Hons), RM

Revised July 2013

OBJECTIVES slide 2 After completing this chapter, participants will be able to: 1. Identify types of birth crisis encountered in practice. 2. Describe the varying emotional responses to birth crises. 3. Describe an approach to handling a birth crisis utilizing the expanded four Cs mnemonic. 4. Identify support groups and agencies to assist families with a birth crisis. 5. Identify resources for health professionals after a birth crisis

“And ever has it been that love knows not its own depth slide 3 until the hour of separation.” (– Khalil Gibran)

BACKGROUND slide 4 Birth Crisis includes, but is not limited to: • Spontaneous pregnancy loss in first and second trimester • Stillbirth • Neonatal death (death of the baby within the first four weeks of life) • Diagnosis of abnormality compatible with life • Diagnosis of abnormality incompatible with life • Critical maternal illness or death during the peripartum period

For the purposes of this chapter the term ‘birth crisis’ is used to describe an adverse outcome of pregnancy resulting in a loss for the parent(s), critical illness of the mother, or death of the mother. slide 5 When women and their partners experience this type of loss, the effects are often profound, causing long-lasting emotional trauma not only to the parent(s) but also to family members.1-4

Provider management of these crises is of great importance since parents may recall, many years after the event, the words used by the practitioner, and the provider’s ability to interact with them.3,5,6

Birth crisis also affects those who provide care to these women and their families. Health care professionals can experience significant emotional trauma.7,8 While the depth and level of loss is generally not as profound as for the family, it can still have a significant impact on the wellbeing of the health care provider, especially if multiple losses over time are experienced.

— Chapter R: Birth Crisis: Caring for the Family Experiencing Perinatal Death or the Birth of a Child With Medical Complications — 1 In caring for women and families who experience birth crisis, health care professionals must seek slide 6 to provide mindful, compassionate, and empathetic care. Accusations and blame are never helpful and indeed may prevent or delay a positive resolution in the process of dealing with grief and loss. Compassionate, humanistic psycho-social management of adverse birth outcomes is imperative for all providers of maternity care.9

The ability of the health care practitioner to provide this care may be hindered by the clinical detachment often required in a busy practice and the absence of emotional support by colleagues.8,10 It is not unusual for a busy physician or midwife to assist in the birth of a stillborn baby and then rush to the birth of a healthy newborn or return to a busy clinic practice with no time to process the grief and loss experienced. slide 7 This chapter will address the needs of the parents and family members following a birth crisis and recommend ways in which practitioners can support parents and provide effective care. Provider resources will also be offered and suggestions on how to better support each other during and following birth crisis will be discussed.

EMOTIONAL SUPPORT IN BIRTH CRISIS Perinatal bereavement is an emotional and difficult time for all involved and the needs and support of the parents and family are paramount. However, the needs of the practitioner should not be over- looked. Despite the constancy of death and the inevitability of distress when a birth crisis occurs, practitioners are often uncertain or ill prepared on how best to proceed and often have anxieties that they will “say the wrong thing.” Some practitioners are able to develop a routine that serves them well. However, others flounder or are overwhelmed by the enormity of parental grief and loss.

There is no universal approach for these situations. Practitioners should acknowledge this and do all that is possible to empathize with parental grief and humanize the situation.10 There is not evidence from randomized controlled trials (RCT) to determine the specific psychological support or counseling needs of parents and families after perinatal death.11 It will depend on the circumstances, context, and expressed needs of the family. However, even after counseling, many families report receiving inadequate emotional support from their health care provider.12,13 In their guideline on stillbirth and late intrauterine fetal death (IUFD), The Royal College of Obstetrics and Gynecology in the UK acknowledges that many strategies have been described for discussing bad news and that a crucial component is determining the emotional feelings and needs of the mother and her support team.14 The empathetic approach seeks to identify women’s thoughts and wishes but without trying to shape them.15

Women and their partners generally want support from their care providers. In one study about neonatal death, women felt sad when they perceived that they received too little support from professionals, particularly related to the time they could spend with their baby. They were also dis- appointed when those looking after them neither acknowledged nor validated their motherhood. These women also felt hurt when health professionals lacked respect or when they felt abandoned by those who were meant to be providing care. These feelings turned to anger when they were treated with indifference or practitioners were callous towards their loss.7

2 — — Chapter R: Birth Crisis: Caring for the Family Experiencing Perinatal Death or the Birth of a Child With Medical Complications Understanding how parents process and address grief can be useful for practitioners. Drotar, Baskiewicz and Irvin16 have a model that helps describe the adaptation of parents to the birth of an infant with a congenital malformation. The main feelings in the model experienced by parents are: Shock, Denial, Sadness, Anger, Equilibrium and Reorganization.16 Most parents will experience these feelings at different times following birth crisis but the length of time taken to navigate the complex process of mourning will differ in each case.4 Many of the issues in their model are useful in perinatal death as well.

There can also be discordant grieving where parental grief is equal but different. This can create tension and disruption in relationships following birth crisis. This is important because the ability for the mother to talk to the father about the stillborn baby in the postpartum period has been shown to result in a reduced risk of maternal depression.17

It is often difficult for parents to know how to help their children cope with the death of a sibling. The parent often tries to maintain a balance between mourning the loss of their child and yet maintaining the normalcy of everyday life for the other sibling(s).18 The profound parental grief can cause unintended neglect of the older siblings and failure to explain and comfort adequately.19 This can cause feelings of guilt in the older child(ren). The child may, even from a young age sense the change in the family dynamic and this may cause confusion and a feeling of insecurity.20 The grief a sibling experiences may be as intense as that of the parents and yet most parents are completely unprepared and have no resources available to help them.21 Unresolved grief can last for many years.21

Other family members including grandparents may also suffer grief and mourning following a pregnancy loss.20 Grandparents not only mourn the loss of their grandchild but also feel sadness and a sense of helplessness at the intensity of their child’s grief.22 Grandparents may have very different ideas than their adult children about how to process grief and believe that talking to children about death is harmful. Parents and their relatives may be at a loss as to how to help each other resulting in a disruption of relationships.23

A study by Roose and Blanford in 2011.20 demonstrated evidence that intergenerational perinatal bereavement programs can help all family members, including siblings and grandparents, understand the mourning process and cope better with pregnancy loss. The guidance and support offered by a professional team was positively received by grandparents.

The ALSO chapter on Safety in Maternity Care, describes the four C’s comprising of compassion, competence, confession and charting which are utilized when an adverse outcome occurs or a medical error is made. Building on this approach, a provider’s actions and care of the patient and her family could be outlined with a second four C’s mnemonic for the care of women and families after a birth crisis slide 8 C - Coming together: Ensuring the right time, place and environment. C - Communication and consideration: What is the goal of this encounter? What do I know, what can I do to help, how will I do it? What will I say and how best to say it? Maintain a mindful, empathetic and caring manner and approach. C - Contact: We should not be afraid of making emotional or physical contact C - Consultation: Do we need to discuss issues or seek guidance from others for advice and support? Do the parents and family need additional information, counseling or support from internal or external agencies? Do we need similar support for ourselves?

— Chapter R: Birth Crisis: Caring for the Family Experiencing Perinatal Death or the Birth of a Child With Medical Complications — 3 Guidelines for initial management of a birth crisis are outlined in Figure 1 and are adapted from Managing Adverse Birth Outcomes: Helping Parents and Families Cope.24

Figure 1: Guidelines for initial management of adverse pregnancy or birth outcome 24 slides 9-14

•Meet with the woman and her partner as soon as possible. •Share the information with both parents together, if possible. •Express feelings for the parent’s loss – e.g. “I am sorry for the loss of your baby” •Remember that saying “I am sorry this happened” in the case of neonatal asphyxia or birth trauma is not considered a confession of guilt. •Involve family members as appropriate for psychosocial support and information sharing. •Sit at eye level. •Do not be afraid of physical contact if accepted by parent(s). •Do not be concerned to display some of the emotion you are experiencing. •Avoid medical jargon. •Enable and support parents to express their feelings. •Recognize that guilt and self-blame are common. •Review the facts but acknowledge their limits (do not be afraid to say “I don’t know why”). •Avoid assigning blame and or premature diagnostic labels. •Recognize that most parents must attach before letting go and that parental grief may be equal but expressed differently (maternal reactions are based on degree of prenatal attachment whereas paternal reactions are based on connectedness to pregnancy, a sense of fatherhood and image of the infant). •Encourage parents to see and hold the infant. In the case of a severely deformed infant holding the baby completely wrapped in a blanket and exposing a foot or hand may be sufficient. •Talk about and value the normal aspects of the infant. •Allow the parent(s) to take their time with this process. •Offer mementoes such as footprints, hair, photographs. (If parents decline these initially they may return at a later date requesting them. A safe storage process is necessary). It is important to take photographs that are flattering – black and white photos often work well. Photos of the baby’s hands and feet or of the parents holding the baby wrapped are often treasured by the family. •Plan the timing of follow up meetings and enable family members to attend if the parents wish. •Undertake ongoing assessments of the needs of the family. •Attend to the patient and family’s emotional concerns. •Involve social workers / counselors specialized in grief with children to help parents support other siblings. •Give resources and guidance for funeral arrangements / memorial service plans. •Monitor maternal physical, social and emotional health and refer to other providers if required. •Address financial issues and refer to social services if possible. •Anticipate anniversary grief and explain to families that this is likely to occur.

4 — — Chapter R: Birth Crisis: Caring for the Family Experiencing Perinatal Death or the Birth of a Child With Medical Complications An institutional standardized check list should be utilized to ensure all aspects of care are consistently and appropriately managed including mementoes for a memory box, photographs taken, death certificates completed, funeral arrangements prepared and appropriate testing done to try and establish the cause perinatal loss.25

STILLBIRTH AND NEONATAL LOSS Definitions:

Stillbirth The World Health Organization (WHO) defines stillbirth as a “fetal death late in pregnancy” and allows each country to define the minimum gestational age. In the United Kingdom the accepted gestational age is 24 completed weeks.26 In Australia, a stillborn is defined as a baby weighing more than 400 grams, or if weight is unknown, more than 20 completed weeks of gestation. These infants must have their birth registered.27

In the USA, the definition of stillbirth varies per state. The Centers for Disease Control (CDC) maintains a list of current definitions found at www.cdc.gov/nchs/products/other/miscpub/statereq.htm. According to the 1992 Model State Vital Statistics Act and Regulations the reporting requirement recommendation is as follows:

“Each fetal death of 350 grams or more, or if weight is unknown, of 20 completed weeks gestation or more, calculated from the date last normal menstrual period began to the date of delivery, which occurs in this state shall be reported within five days after delivery to the (Office of Vital Statistics) or as otherwise directed by the State Registrar.”

The lack of a clear definition and lack of accurate global recording of stillbirth complicates and compromises data collection and research into the causes and thus, prevention.28

Neonatal Loss Neonatal loss is defined as the death of a baby after live birth in the first 28 days (four weeks) of life.29 The emotional responses of the family and health care providers to neonatal death occurring soon after birth as well as the etiologies of the loss and medical evaluation have many similarities. Early neonatal death (within the first seven days) may reflect an unanticipated outcome of the birth process (e.g. neonatal encephalopathy), postnatal events (e.g. sepsis) or occur secondary to lethal anomalies that may or may not have been known prior to birth.

Prevention It is essential that we begin to better understand the underlying causes of stillbirth. Medical cause such as diabetes, infection, congenital abnormalities, obesity, smoking, advanced maternal age, placental dysfunction pre-eclampsia, or other conditions which inhibit fetal growth, are linked to early pregnancy loss, miscarriage and stillbirth.14 Women with a pregnancy history of preterm birth and/or intra-uterine growth retardation are at higher risk of stillbirth in a subsequent pregnancy.30,31 Women living on the margins of society or from particular ethnic groups are also at increased risk.32 The risk should be discussed with parent(s) pre-conceptually and continually through the prenatal period. Providers and institutions need to evaluate and audit care, documenting and researching outcomes and alternatives, so that in future, risks may be readily identified and preventative measures developed.

— Chapter R: Birth Crisis: Caring for the Family Experiencing Perinatal Death or the Birth of a Child With Medical Complications — 5 Evidence Based Management All providers of maternity care are likely to encounter an unexpected adverse birth outcome at some point in their career. Diagnosis of intrauterine fetal death (IUFD) may follow a maternal concern about decreased fetal movement or it may come as a complete surprise when the fetal heart is not heard during a routine exam. In developed countries ultrasound will usually be utilized to confirm the finding.

When a maternity care provider suspects fetal demise it is not acceptable for a couple to be left with uncertainty or a long wait until the final diagnosis is reached. Depending upon their level of expertise with obstetrical ultrasound the maternity care provider performing the ultrasound demon- strating a lack of fetal heart motion may desire to have a second examiner confirm the diagnosis. The woman should be informed in a private space, preferably with her partner or support person. She and her family will need time to come to terms with the news. Sometimes several meetings are needed for the parents to understand what has happened.24,33 The provider will need to be aware of the amount of information being conveyed as well as the amount being absorbed and be willing to repeat information several times in order to ensure full understanding. The provider must make every attempt to make time so that meetings are not rushed to try and avoid the frequent perception of lack of support.34

In the case of an intrauterine death, induction of labor will usually be offered in the next few days. slide 15 In the absence of acute maternal illness there is no urgency and offering the option of induction or expectant management is reasonable and may be beneficial psychologically.35 Dilation and extraction (D&E) may be a preferred option for second trimester loss if a physician skilled in the procedure is available.36 Lengthy delays in induction (over two weeks) potentially increase the risk of maternal coagulopathy.37 Cervical ripening may be required in a case of recent stillbirth. Adequate analgesia/ anesthesia must be made available and women’s wishes in terms of the labor and birth need to be accommodated and respected. Many women will be anxious about the thought of a labor and giving birth to a stillborn baby. Some women may ask for a cesarean section at this stage. Avoiding cesarean section and the well-documented potential for maternal morbidity without fetal benefit is encouraged except in unusual circumstances such as a prior vertical uterine incision or women with more than two prior cesarean deliveries. Women with one or two prior cesarean deliveries may receive prostaglandins for cervical ripening and induction after careful counseling regarding the maternal risk.35 Continuity of care through this time is very important for most families.

A neonatal death due to birth asphyxia or unanticipated neonatal illness will likely be preceded by urgent and emergent care for the baby. In this scenario the parent(s) may witness a resuscitation attempt or they may be excluded as the baby is taken to a treatment room or an intensive care unit for treatment. In the absence of a prenatal diagnosis of abnormality this death will often come as a complete surprise and as in the case of a stillbirth, compassion, adequate time and understanding are the key components of immediate care.

Communication with the entire health care team including midwives, nurses, pastoral care, physicians (including residents if involved), social workers, and NICU staff is important so that consistent and accurate information is offered to the family. A standardized protocol to provide consistent care especially in units that rarely handle stillbirth cases is beneficial.30 Identifying the event of a loss by marking the door of the woman’s room with a standardized system will help all the health care team, including ancillary staff have an awareness of the need for sensitivity when entering the room.38

6 — — Chapter R: Birth Crisis: Caring for the Family Experiencing Perinatal Death or the Birth of a Child With Medical Complications Adequate time to hold and be with the baby has been demonstrated to be beneficial in emotional recovery following stillbirth after 37 weeks. The benefit in holding a stillborn baby between 28 and 37 weeks is uncertain and requires more study although experience shows most parents benefit from this if it is undertaken sensitively and in a supportive manner.39

Recommended evaluation for the etiology of stillbirth Figure 2 There are currently no internationally recognized, evidence based guidelines for the evaluation for the etiology of stillbirth.

A 2012 prospective multi center prospective cohort study concluded that autopsy, placental examination, cytogenetic analysis, and testing for fetal maternal hemorrhage are the tests with the greatest likelihood of identifying a specific etiology for the loss.32 Perinatal autopsy is under-utilized in many countries including the USA with rates of 35 percent in tertiary centers in Utah and only 13.3 percent in community hospitals in the same state.40

Reasons for the global under-utilization may include lack of funding in low resource countries, few pathologists with experience and expertise in perinatal autopsy, lack of remuneration for perinatal autopsy and parental misunderstanding of the potential value of the autopsy.41

The American College of Obstetrics and Gynecology (ACOG) has a practice bulletin published in 2009 for the evaluation of the etiology of stillbirth.34 Amniocentesis, fetal autopsy, examination of the placenta, cord, membranes, and fetal karyotyping were recommended investigations.34

In 2010 The Royal College of Obstetricians and Gynecology (RCOG) in the United Kingdom published a Late Intrauterine Death and Stillbirth Guideline and provides recommendations for evaluation based on specific clinical scenarios.44 The Perinatal Society of Australia and New Zealand (PSANZ) also developed a 2009 Clinical Guideline for the evaluation of potential etiologies of stillbirth.43

The clinician should discuss options for evaluation with the parent(s) based on the guidelines recommended in their country and allow the parent(s) to decide how they wish to proceed.

Figure 2: Evaluation of Stillbirths slide 16 Fetal Studies Maternal Studies Amniotic fluid analysis Prenatal genetic evaluation (amniocentesis Autopsy (with parental consent) at time of diagnosis of abnormalities or stillbirth) Photographs of fetus* Thrombophilia workup Fetal karyotype analysis (cord blood, placenta and cord or fetal tissue) Placental examination Internal fetal specimen: (Placental block 1 cm x 1 cm taken from below cord insertion site. Umbilical cord segment 1.5 cm. Internal tissue specimen such as costochondral junction or patella. Specimens to be placed in a sterile tissue medium of lactated Ringer’s solution kept at room temperature.)

— Chapter R: Birth Crisis: Caring for the Family Experiencing Perinatal Death or the Birth of a Child With Medical Complications — 7 In addition to the studies described above, it is prudent to take photographs of the baby. Photographs should include: whole body, frontal and profile views of face extremities and palms and of any specific abnormalities. It is important to document all findings particularly any abnormalities. Remember that the family may read your descriptions at some time in the future so be careful to write in a sensitive and respectful manner.

CARE OF WOMEN IN SUBSEQUENT PREGNANCY There is little evidence to guide the care of women following an unexplained stillbirth. In low risk women following an unexplained stillbirth, the risk of a stillbirth in a subsequent pregnancy after 20 weeks ranges from 7.8 to 10.5 in 1,000.34

The risks of early induction of labor for a woman with an uncomplicated subsequent pregnancy, following a prior unexplained stillbirth before 39 completed weeks of gestation, must be weighed against the real risks of an early or late preterm birth.44 Although it has been a common practice to induce prior to 39 weeks with such a history this is no longer recommended based on a 2011 workshop sponsored by National Institute of Child Health and Human Development and Society for Maternal-Fetal Medicine.45

It is reasonable to consider serial growth ultrasounds beginning at 28 weeks if there is lag in fundal height measurement or other concern about fetal growth, as intra uterine growth retardation is associated with a stillbirth risk of 21.8 per 1,000.48 ACOG recommends beginning fetal surveillance starting at 32 weeks gestation or one to two weeks earlier than prior stillbirth.23 There is an estimated 1.5 percent rate of iatrogenic prematurity for intervention based on a false positive result during antenatal surveillance.47

Amniocentesis to assess fetal lung maturity to permit delivery under 39 weeks is not a recommended approach since there are other organ systems to consider prior to initiating an induction before 39 completed weeks; however if a maternity care provider and their patient do choose delivery at < 39 weeks it may be considered.45,46

There is evidence that decreased fetal movements are associated with adverse outcomes, therefore, educating a woman to be aware of fetal movements engages her in the monitoring of her baby. Unfortunately, there is not good evidence to show that maternal monitoring of fetal kick counts prevents stillbirth.48 Emotional support will be an essential component of any care. More frequent antenatal visits while not necessarily preventing recurrence, may offer reassurance. Listening to concerns and helping steer women through their anxieties, especially towards the end of pregnancy is important. Once again, continuity of care provider is likely to be beneficial.

Management of Second Trimester Loss Second trimester loss deserves the same emotional care and support outlined above. Clinical management following diagnosis includes offering the option of labor induction or dilatation and evacuation (D&E).34 Usually this will depend on maternal preference and the ability to find a provider skilled in second trimester D&E. Maternal grief resolution is not affected by the choice of termination if the woman self-selects the process.36 In the USA most second trimester pregnancy terminations are completed by a D&E, however, in the late second trimester medical induction becomes the more common procedure for fetal anomalies.49 The benefits of labor induction are the ability to better evaluate for fetal anomaly and the ability for parent(s) to see and hold the baby. Chromosomal analysis can be performed on products obtained from D&E.49

8 — — Chapter R: Birth Crisis: Caring for the Family Experiencing Perinatal Death or the Birth of a Child With Medical Complications Misoprostol, as a single agent administered vaginally or sublingually, is an effective form of labor induction following second trimester loss.50,52 Use of misoprostol to induce labor is considered safe in patients with a prior cesarean birth with a low transverse scar before 28 weeks gestation [11]. From 13 to 17 weeks use 200 mcg every 6 to 12 hours with the potential to double the dose to 400 mcg q 6 to 12 hours if the first dose does not result in adequate contractions. For 18 to 26 weeks start with 100 mcg q 6 to 12 hours and consider doubling to 200 mcg q 6 to 12 hours if the first dose does not provide adequate contractions. In women with a prior uterine scar consider a lower initial dose and do not double after the first dose is given.50,52

Prenatal diagnosis of abnormality While there has been an increase in the amount of research into the effects on parents and families of perinatal loss there remains little research available regarding the psychological effects of the diagnosis of an abnormality and the decision to terminate the pregnancy as a result. Without “full disclosure” and transparency, parents are hardly prepared to make an informed choice as to whether to test or not. Before proceeding with testing parents need to be carefully counseled as to the limits of testing and the potential choices they may face.

The same emotional support and counseling should be made available to parents who choose to terminate a pregnancy as to those who experience the spontaneous loss of a baby.

THE BABY WITH AN ABNORMALITY OR DISABILITY Caring for a child with disabilities is a stressful situation for the parents, and the best predictor of the level of stress is the severity of the disability.52,53 slide 17 Caregivers of children with intellectual disabilities are likely to suffer from depression.54 The depression may be the result of the financial, social and physical stressors experienced by the family.55

Parents with a baby born with a disability or abnormality should be offered the same emotional support as described in this paper. There is some evidence that family centered care provides the best support for caregivers of children with disabilities.56 A family physician is likely to be a caregiver for the family and possibly the child over the long term and is in a prime position to help diagnose and provide family support. Parents should be offered information about community resources available for the particular condition and directed to any support groups that are available.

Maternal Critical Illness and Death slide 18 While this chapter concentrates on the experience of birth crisis in relation to the baby, the death of or critical illness of a mother in pregnancy or around childbirth is equally important and distressing for all. Maternal critical illness may be related to prior co-morbidities such as obesity or hypertension. It may also occur as a result of a pregnancy complication such as pre eclampsia or hemorrhage. Prenatal recognition of a high-risk pregnancy is important in ensuring the appropriate level of care is offered with the utilization of and referral to the maternal fetal medicine team as appropriate. All facilities providing obstetric care must be prepared to handle emergencies such as massive blood loss, maternal seizure and sepsis. The implementation of evidence-based protocols will help guide providers in facilities without immediate access to an intensive care team.57 The regular practice of team based drills to manage obstetric emergencies has been shown to improve outcomes.58

— Chapter R: Birth Crisis: Caring for the Family Experiencing Perinatal Death or the Birth of a Child With Medical Complications — 9 In developing countries maternal death is rare and usually unexpected when it occurs. The maternal mortality rate in the United States appears to no longer be decreasing, perhaps due to the obesity epidemic and the increased proportion of births that are by cesarean. In Australia, maternal death is unexpected and the numbers of deaths are small. However, across Australia more than one woman dies every two weeks in circumstances associated with childbearing.59 In the USA the pregnancy- related mortality ratio was 15.1 deaths per 100,000 live births for the period 2006–2007.60 Every maternal death has a major impact on the family, the community and the health care providers who were involved.61

Maternity care providers’ experience of the death of a mother has been shown to be comparable with that of emergency personnel attending large-scale disasters and most maternity providers are completely unprepared.61 Maternity care providers also report having flashbacks and memories of the death also impinge on personal and professional relationships.61

While this chapter focuses on the loss of a baby, the principles of providing support to families who experience birth crisis are essentially the same for families and staff who experience a maternal death.

HEALTH CARE PROVIDERS slide 19 Health care providers struggle with their own fears that they have either missed something that could have prevented this outcome or have directly contributed to the outcome. The amount of support that providers need to deal with their own grief or fears should not be under-estimated.

A number of mostly qualitative studies have explored providers’ experiences related to perinatal loss. One common theme from these studies is that staff often experience guilt as they feel that their role is about saving lives rather than being around death.44 Guilt is also tied up with blame and sometimes, blaming one another for not doing enough to give emotional support to the woman and families.62-64 Personal grief has been found to be common in obstetricians following the care of a woman experiencing a stillbirth. Self doubt, self blame and depression were also frequent reactions experienced by the physician.8

Another common response is rationalization where staff compartmentalize the difficult and sad aspects of their role to manage later.44 This is especially the case when working in busy environments. In these environments, there is often little time to grieve, acknowledge the event, and assess how they might be impacted by them.63 Unresolved personal issues also affect the way health care providers cope themselves and these need to be addressed.63

There are a number of strategies that are useful for the wellbeing of health care providers. These include reflection and review; emotional and practical support; access to counselling services; initial and ongoing education and training; institutional policies and guidelines.62

Reflection and review slide 20 Seeking out people to discuss the tragedy and its personal impact can be helpful. Formal reflection on the care of the woman during her pregnancy with colleagues is also very important. Many hospitals or health settings will have regular perinatal mortality meetings where the care of women who have had a stillbirth or neonatal death will be discussed. These meetings should provide a safe and confidential environment for care providers to reflect upon the care provided and to determine

10 — — Chapter R: Birth Crisis: Caring for the Family Experiencing Perinatal Death or the Birth of a Child With Medical Complications whether anything could have been done differently. Changes in policy and practice to reduce the risk of similar events occurring in the future should be addressed.42

Fear of litigation has been identified as one concern from health care providers involved in this area,64 which needs to be acknowledged so that it does not affect future practice adversely.

Emotional and practical support Support from colleagues, both emotional and practical, is essential. Health care providers who work in a supportive environment that has a no-blame culture are more likely to provide better, more effective care and be able to make changes in their practice to improve care in the future.62

Time pressures have been identified by care providers as a barrier to providing and receiving support. It is important for managers and other in leadership positions to seek out staff that have been involved in caring for families that have experienced perinatal loss and ensure they have adequate support. Looking after you own team members is also necessary.

Midwives’ satisfaction with working with families experiencing perinatal loss was related to the level of support they received from the organization in which they worked.64 This includes being in a hospital that acknowledged loss and grieving, as well as, being able to provide continuity of care to these families.65

Access to counselling services Some health services offer a bereavement counsellor and this has been found to be useful.63 This type of counselling may also be provided in a group rather than one-on-one. Peer support groups, multidisciplinary team meetings and formal debriefing with trained personnel are all strategies that can provide support for clinicians. An element of personal healing needs to take place to enable health care providers to move beyond the strong emotions after a perinatal loss.64

Initial and ongoing education and training Newer obstetrical providers and staff may need mentoring to care for families who experience perinatal loss.59 Families who have experienced perinatal loss should be included in the education and training programs for maternity care staff.62,63,66 This could also include communication training and role playing breaking the bad news and expressing condolences appropriately to families experiencing perinatal loss.67 Just knowing what to say and being brave enough to say it needs to be included in training programs.65

There also needs to be an emphasis on the emotional and psychological aspects of perinatal loss and grief, as well as on the sound theoretical knowledge of grief.63 Students are often ‘protected’ from working with families experiencing perinatal loss; and, while this is helpful at times, it also means that these students have few skills in this area when they graduate. Students should have the opportunity to develop the clinical experience of caring for bereaving couples under supervision and with compassionate support.62

Education and training is not only important for initial education but also should be part of continuing professional development and ongoing study days or seminar attendance.62

— Chapter R: Birth Crisis: Caring for the Family Experiencing Perinatal Death or the Birth of a Child With Medical Complications — 11 Policies and guidelines Staff caring for families who experience perinatal loss can become overwhelmed especially if they also face staff shortages.63 It is essential that hospitals and health services develop policies and guidelines to help support staff including access to counselling services and support networks.51

In the United Kingdom, statutory midwifery supervision provides a framework of professional support in which a named supervisor is readily available to listen, advise and offer support in times where adverse clinical incidences arise.66,68 This not only ensures that the practitioner is given time to reflect and learn from such events, but also enables them to begin to process the emotions and experiences that arise and if not addressed, might well persist following a birth crisis.69

It is important to be aware of one’s own feelings of loss following a birth crisis. Health care providers are invested in a healthy baby and mother and feel deeply saddened by catastrophic outcomes. It is important not to become defensive or prematurely admit to any wrongdoing as a means of resolving your own grief. If health care providers have suffered a similar loss, it is their discretion whether or not to reveal that information to the family. While each situation is different, this might help to minimize or dilute the parent’s grief.

SUMMARY Birth Crisis is affects women and their families, providers, and obstetrical staff. Provider manage- slide 21 ment of these crises is of great importance and is often challenging because of the emotional trauma, personal responsibility, and fear of litigation. In caring for women and families who experience birth crisis, health care professionals must seek to provide mindful, compassionate, and empathetic care. Accusations and blame are never helpful and indeed may prevent or delay a positive resolution in the process of dealing with grief and loss.

The cases associated with this chapter can assist providers and staff in preparing to handle a slides 22-25 birth crisis in their health care system.

BIRTH CRISIS IN GLOBAL OR LOW RESOURCE ENVIRONMENT Women in developing countries experience birth crisis with a greater frequency than those in developed countries. However, despite the increased frequency, each loss has the potential to be equally devastating. As with recommendations for caring for women experiencing birth crisis in developed countries, evidence for women in developing countries is also lacking.

Social support, as noted above, remains a key element to caring for a woman and her family experiencing a birth crisis. When the crisis occurs outside of the hospital setting, the basis of this support may be from family and the community. In the hospital setting, providers should be cognizant of cultural and religious morays and how they apply to the provision of empathy and sympathy. When possible, translators should be employed to avoid miscommunication and misunderstanding.

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