DOCSLIB.ORG

Cesarean Section Technique: What's New in the Evidence Base?

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Cesarean Section Technique: What's New in the Evidence Base? Cesarean Section Technique: What’s New in the Evidence Base? No Disclosures Marya G. Zlatnik, MD, MMS Maternal Fetal Medicine UCSF Hamano, Teisuke. 1880. Kainin no kokoroe (Information on pregnancy). Japanese Woodblock Print Collection, Archives & Special Collections, UCSF Library & Center for Knowledge Management. Cesarean Rates Continue to Rise Learning Objectives • Review new techniques & literature re: C/S – “Gentle” cesarean – Infection prevention – (Pain control) – Hemorrhage – Sutures • Evidence-base (according to me) 1 Family-Centered or “Gentle” Cesarean UCSF Family-Centered Cesarean • Buy in from OB, Peds, Nursing, Anesthesia • Clear double drapes • Staffing (extra RN) • UCSF Protocol created by Dr. Robyn Lamar Is “family-centered” or “gentle” A. Yes, we docesarean this at my hospitala good idea? B. Yes, we’re working on it C. We do it only because patients ask D. No, I’m worried about infection & E. What isdisruption it? in the OR UCSF Family-Centered Cesarean • 27% • Mother may choose music to be played in OR • Double drape (with clear window) used 23% • Anesthesia places ECG leads away from mother’s chest 42% • Mother’s chest warmed prior to skin-to-skin with instant hot pack Elevate head of bed, to facilitate viewing the birth & skin-to-skin • Yes, we do this at my hos... • After delivery of head, OB delivers body slowly 5% Yes, we’re working on it • After delivery of head, drape dropped if mother desires to see birth 3% • Consider delayed cord clamping for 30-60 seconds We do it only because pa... Pediatricians receive the baby as usual; 1 min APGAR on warmer; goal to be No, I’m worried about in... • back to mom by 5 minutes for skin-to-skin After close, while drapes are removed & mother is cleaned, partner may help What is it? • with weighing baby & observe other routine care Once mother is on recovery bed, baby placed skin-to-skin again & the dyad transported together to recovery +Ev +Ev +Ev 2 Family-Centered or “Gentle” Cesarean Contraindications: • Prematurity • Emergency cesarean • Anticipated resuscitation (ex: anomalies, nonreassuring Protocol inappropriate in some situations & clinical FHR) judgment always takes precedent •Ex: with vasa previa, slow delivery of body inadvisable •Ex: increased BMI, elevating the head of the bed may impact surgical visualization •Ex: insufficient nursing staff to remain with baby in OR Pre-incision Atbx: Decreased SSI vs After Cord Clamp 8 p= 0.002 6 What are your routine prophylactic antibiotics? (no PCN-allergy) 4 SSI (%) A. Any agent given after cord clamp 2 B. Ampicillin pre-incision 12 0 p= 0.014 C. Cephalosporin (cefazolin) pre- Overall Endometritis Cellulitis D. Cefazolinincision + azithromycin 2005-2006 n= 800 E. Other pre-incision After 2006 n= 516 p= 0.020 Kaimal SMFM 2008 Prophylactic Atbx—Extended 77% Spectrum Regimens 2% 11% • RCT adding metronidazole vag gel Any agent given after co.. Ampicillin pre-incision – 224 pts; vaginal gel vs placebo gel 9% Ceph lo or n c az i . – Less endometritis (7 vs 17%), trend towards less a sp i ( ef ol n. Cefazolin + azithromycin 1% fever; no difference in wound infxn, LOS • Ureasplasma increases risk for C/S SSI Other pre-incision – Cephalosporin doesn’t cover – Post-cord-clamp cefotetan plus placebo or doxy+azithro Pitt 2001 Andrews 2003 3 Extended spectrum Prophylaxis • UAB studies over 14 years – In 2000, IV cefotetan or cefazolin & IV azithro at cord clamp 14 – Decreased endometritis – Decreased wound infections Extended spectrum Prophylaxis? • UCSF baseline rate much lower (<1%) • Hesitant to extend atbx spectrum for all C/S pts Tita Tita Concerns– re: atbx resistance, messing up ObGyn Extended spectrum Prophylaxis • Selectively extend atbx spectrum AJOG microbiome 2009 2008 eg,– pt w/ DM/obesity Cefazolin– 2-3g IV preop + azithro 500mg IV after 17 cord clamp (mix in 250mL/give over 1 hr ) • Multicenter RCT: C/SOAP Trial 2013– pts, C/S in labor or ROM (chorio excluded) 15 – Ave BMI 35 (>60% had BMI >30) – Std atbx + Azithro prior to incision – Fewer SSIs, fevers, PP readmits Do you prep the vagina prior to C/S? A. Yes, every case B. Yes, if ruptured membranes C. Yes, if chorio D. No, never Tita NEJM 2016 E. Not sure 18 66% 13% 8% Yes, every case Yes, if ruptured membranes 1% Yes, if chorio 11% No, never Not sure 4 ZMG2 ZMG2 Vaginal Prep prior to C/S Vaginal Cleansing prior to C/S • Povidone-iodine prep -> decreased • New meta-analysis Sept 2017 endometritis, esp w/ ROM • Povidone-iodine prep -> decreased • No difference in fever or wound complications endometritis, fever, esp w/ labor/ROM • ? benefit if already chorio • No difference in wound complications • Possible effect on neonatal thyroid studies • Only 6 of 16 specified pre-incision atbx • Risk of vaginal lac • ? benefit if already chorio • Dahlke gives a “B” – Caissutti ObGYN 2017 – Cochrane 2010, Reid 2001, Rouse 1997, Starr 2005 CORONIS Trial Lancet 2016 • International, pragmatic trial 2x2x2x2x2 • 19 sites in S. America, Africa, India, Pakistan • 1st or 2nd C/S, follow up at 3 yrs • 15,633 women studied: – Blunt vs. sharp abdominal entry – Repair of uterus in or out – 1 vs. 2 layer closure of uterus – Closure vs. non-closure of peritoneum – Chromic vs. polyglactin-910 for uterus • Outcomes of subsequent pregnancies, pain 5 Incision Type, Uterine Repair, Etc. Placental Delivery – CORONIS Trial 2016 Uterine Exteriorization Incision Type, Uterine Repair, Etc. • No differences CORONIS Trial 2016 6 Management of Hemorrhage Uterine repair • CMQCC hemorrhage toolkit V2.0 (revised March 2015) https://www.cmqcc.org/resources-tool- kits/toolkits/ob-hemorrhage-toolkit Photo courtesy of CMQCC and David Lagrew, MD NPR.org CMQCC OB Hemorrhage Obstetric Hemorrhage Emergency Management Plan: Table Chart Format version 2.0 Assessments Meds/Procedures Blood Bank Stage 0 Every woman in labor/giving birth Emergency Management · Assess every woman Active Management · If Medium Risk: T & Scr Management of Hemorrhage Stage 0 focuses for risk factors for 3rd Stage: · If High Risk: T&C 2 U on risk hemorrhage · Oxytocin IV infusion or · If Positive Antibody assessment and · Measure cumulative 10u IM Screen (prenatal or active quantitative blood · Fundal Massage- current, exclude low level management of loss on every birth vigorous, 15 seconds min. anti-D from Plan the third stage. RhoGam):T&C 2 U Blood loss: > 500ml vaginal or >1000 ml Cesarean, or Stage 1 VS changes (by >15% or HR ³110, BP £85/45, O2 sat <95%) Obstetric Emergency Management Plan: Flow Chart Format Release 2.0 7/9/2014 · Activate OB · IV Access: at least 18gauge · T&C 2 Units PRBCs Follow appropriate workups, planning, preparing Hemorrhage Protocol (if not already done) Identify patients with special consideration: · Increase IV fluid (LR) and Pre- Placenta previa/accreta, Bleeding disorder, or of resources, counseling and notification Stage 1 is short: and Checklist Oxytocin rate, and repeat Admission those who decline blood products Verify Type & Screen on prenatal activate · Notify Charge nurse, fundal massage record; Low Risk: Draw blood and hold specimen if positive antibody screen on prenatal hemorrhage OB/CNM, Anesthesia · Methergine 0.2mg IM (if Time of Screen All Admissions for hemorrhage risk: Medium Risk: Type & Screen, Review Hemorrhage Protocol or current labs (except low level anti-D protocol, initiate · VS, O2 Sat q5’ not hypertensive) Low Risk, Medium Risk and High Risk High Risk: Type & Crossmatch 2 Units PRBCs; Review Hemorrhage from Rhogam), Type & Crossmatch 2 preparations and · Record cumulative May repeat if good admission Protocol Units PBRCs give Methergine blood loss q5-15’ response to first dose, BUT nd IM. · Weigh bloody materials otherwise move on to 2 Ongoing Cumulative Blood Loss rd · Careful inspection with level uterotonic drug (see Stage 0 All women receive active management of 3 stage Evaluation: >500 ml Vag; >1000 ml CS NO Standard Postpartum below) Oxytocin IV infusion or 10 Units IM, 10-40 U infusion Quantification of >15% Vital Sign change -or- Management good exposure of All Births blood loss and HR ≥ 110, BP ≤ 85/45 Fundal Massage vaginal walls, cervix, · Empty bladder: straight cath vital signs O2 Sat <95%, Clinical Sx uterine cavity, placenta or place foley with urimeter INCREASED BLEEDING Blood Loss: YES >500 ml Vaginal Increase IV Oxytocin Rate Stage 2 Continued bleeding with total blood loss under 1500ml Methergine 0.2 mg IM (if not hypertensive) Activate Hemorrhage Protocol nd >1000 ml CS OB back to bedside (if 2 Level Uterotonic Drugs: · Notify Blood Bank of Vigorous Fundal massage; Empty Bladder; Keep Warm CALL FOR EXTRA HELP Stage 1 not already there) · Hemabate 250 mcg IM or OB Hemorrhage Administer O2 to maintain Sat >95% Increased nd Activate Rule out retained POC, laceration or hematoma NO Postpartum · Extra help: 2 OB, · Misoprostol 800 mcg SL · Bring 2 Units PRBCs Continued heavy Stage 2 is nd Hemorrhage Order Type & Crossmatch 2 Units PRBCs if not already done Rapid Response Team 2 IV Access (at least to bedside, transfuse bleeding Surveillance focused on Protocol (per hospital), assign 18gauge) per clinical signs – do YES sequentially Blood Loss: Vaginal Birth: roles Bimanual massage not wait for lab values CALL FOR EXTRA HELP advancing Bimanual Fundal Massage · VS & cumulative Vaginal Birth: (typical order) · Use blood warmer for 1000-1500 ml Give Meds: Hemabate 250 mcg IM -or- through Retained POC: Dilation and Curettage blood loss q 5-10 min · Move to OR transfusion Misoprostol 600-800 SL or PO medications and Stage 2 Lower segment/Implantation site/Atony:
Load more

Recommended publications
  • Postpartum Haemorrhage
    Guideline Postpartum Haemorrhage Immediate Actions Call for help and escalate as necessary Initiate fundal massage Focus on maternal resuscitation and identifying cause of bleeding Determine if placenta still in situ Tailor pharmacological management to causation and maternal condition (see orange box). Complete a SAS form when using carboprost. Pharmacological regimen (see flow sheet summary) Administer third stage medicines if not already done so. Administer ergometrine 0.25mg both IM and slow IV (contraindicated in hypertension) IF still bleeding: Administer tranexamic acid- 1g IV in 10mL via syringe driver set at 1mL/minute administered over 10 minutes OR as a slow push over 10 minutes. Administer carboprost 250micrograms (1mL) by deep intramuscular injection Administer loperamide 4mg PO to minimise the side-effect of diarrhoea Administer antiemetic ondansetron 4mg IV, if not already given Prophylaxis Once bleeding is controlled, administer misoprostol 600microg buccal and initiate an infusion of oxytocin 40IU in 1L Hartmann’s at a rate of 250mL/hr for 4 hours. Flow chart for management of PPH Carboprost Bakri Balloon Medicines Guide Ongoing postnatal management after a major PPH 1. Purpose This document outlines the guideline details for managing primary postpartum haemorrhage at the Women’s. Where processes differ between campuses, those that refer to the Sandringham campus are differentiated by pink italic text or have the heading Sandringham campus. For guidance on postnatal observations and care after a major PPH, please refer to the procedure ‘Postpartum Haemorrhage - Immediate and On-going Postnatal Care after Major PPH 2. Definitions Primary postpartum haemorrhage (PPH) is traditionally defined as blood loss greater than or equal to 500 mL, within 24 hours of the birth of a baby (1).
    [Show full text]
  • Ⅰ Obstetric Hemorrhage Safety Bundle Implementation in a Rural
    Obstetric Hemorrhage Safety Bundle Implementation in a Rural CAH Dale C Robinson MD,FACOG Chief Ob/Gyn Grande Ronde Hospital La Grande Oregon S Planning for and Responding to Obstetric Hemorrhage California Maternal Quality Care Collaborative Obstetric Hemorrhage Version 2.0 Task Force This project was supported by Title V funds received from the California Department of Public Health; Maternal, Child and Adolescent Health Division 2 CMQCC S California Maternal Quality Care Collaborative S Multidisciplinary Task Force S Recommendations/ Obstetric Safety Bundle S Yellow/Blue Slides Maternal Mortality Rates, Moving Average, California Residents; 1999-2010 16 14 14.0 12.2 13.5 13.2 12 12.7 11.6 12.1 11.5 10 9.4 10.2 8 6 4 Maternal Deaths per 100,000 Live Births 2 0 1999-2001 2000-2002 2001-2003 2002-2004 2003-2005 2004-2006 2005-2007 2006-2008 2007-2009 2008-2010 Three-Year Moving Average SOURCE: State of California, Department of Public Health, California Birth and Death Statistical Master Files, 1999-2010. Maternal mortality for California (deaths ≤ 42 days postpartum) was calculated using ICD-10 cause of death classification (codes A34, O00-O95,O98-O99) for 1999-2010. On average, the mortality rate increased by 2% each year [(95% CI: 1.0%, 4.2%) p=0.06. Poisson regression] for a statistically significant increasing trend from 1999-2010 (p=0.001 one-sided Cochran-Armitage, based on individual year data). Produced by California Department of Public Health, Center for Family Health, Maternal, Child and Adolescent Health Division, December, 2012. North Carolina: Mortality Mostly Preventable Cause of Death (n=108) % of All Deaths % Preventable Cardiomyopathy 21% 22% Hemorrhage 14 93 PIH 10 60 CVA 9 0 Chronic condition 9 89 AFE 7 0 Infection 7 43 Pulmonary embolism 6 17 Berg CJ, Harper MA, Atkinson SM, et al.
    [Show full text]
  • • Chapter 8 • Nursing Care of Women with Complications During Labor and Birth • Obstetric Procedures • Amnioinfusion –
    • Chapter 8 • Nursing Care of Women with Complications During Labor and Birth • Obstetric Procedures • Amnioinfusion – Oligohydramnios – Umbilical cord compression – Reduction of recurrent variable decelerations – Dilution of meconium-stained amniotic fluid – Replaces the “cushion ” for the umbilical cord and relieves the variable decelerations • Obstetric Procedures (cont.) • Amniotomy – The artificial rupture of membranes – Done to stimulate or enhance contractions – Commits the woman to delivery – Stimulates prostaglandin secretion – Complications • Prolapse of the umbilical cord • Infection • Abruptio placentae • Obstetric Procedures (cont.) • Observe for complications post-amniotomy – Fetal heart rate outside normal range (110-160 beats/min) suggests umbilical cord prolapse – Observe color, odor, amount, and character of amniotic fluid – Woman ’s temperature 38 ° C (100.4 ° F) or higher is suggestive of infection – Green fluid may indicate that the fetus has passed a meconium stool • Nursing Tip • Observe for wet underpads and linens after the membranes rupture. Change them as often as needed to keep the woman relatively dry and to reduce the risk for infection or skin breakdown. • Induction or Augmentation of Labor • Induction is the initiation of labor before it begins naturally • Augmentation is the stimulation of contractions after they have begun naturally • Indications for Labor Induction • Gestational hypertension • Ruptured membranes without spontaneous onset of labor • Infection within the uterus • Medical problems in the
    [Show full text]
  • Obstetrics Seventh Edition
    PROLOGObstetrics seventh edition The American College of Obstetricians and Gynecologists WOMEN’S HEALTH CARE PHYSICIANS Obstetrics seventh edition Assessment Book The American College of Obstetricians and Gynecologists WOMEN’S HEALTH CARE PHYSICIANS ISBN 978-1-934984-22-2 Copyright 2013 by the American College of Obstetricians and Gynecologists. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, posted on the Internet, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the publisher. 12345/76543 The American College of Obstetricians and Gynecologists 409 12th Street, SW PO Box 96920 Washington, DC 20090-6920 Contributors PROLOG Editorial and Advisory Committee CHAIR MEMBERS Ronald T. Burkman Jr, MD Bernard Gonik, MD Professor of Obstetrics and Professor and Fann Srere Chair of Gynecology Perinatal Medicine Tufts University School of Medicine Division of Maternal–Fetal Medicine Division of General Obstetrics and Department of Obstetrics and Gynecology Gynecology Department of Obstetrics and Wayne State University School of Gynecology Medicine Baystate Medical Center Detroit, Michigan Springfield, Massachusetts Louis Weinstein, MD Past Paul A. and Eloise B. Bowers Professor and Chair Department of Obstetrics and Gynecology Thomas Jefferson University Philadelphia, Pennsylvania Linda Van Le, MD Leonard Palumbo Distinguished Professor UNC Gynecologic Oncology University of North Carolina School of Medicine Chapel Hill, North Carolina PROLOG Task Force for Obstetrics, Seventh Edition COCHAIRS MEMBERS Vincenzo Berghella, MD Cynthia Chazotte, MD Director, Division of Maternal–Fetal Professor of Clinical Obstetrics and Medicine Gynecology and Women’s Health Professor, Department of Obstetrics Department of Obstetrics and Gynecology and Gynecology Weiler Hospital of the Albert Einstein Thomas Jefferson University College of Medicine Philadelphia, Pennsylvania Bronx, New York George A.
    [Show full text]
  • Safety Profile of Misoprostol for Obstetrical Indications
    SAFETY PROFILE OF MISOPROSTOL FOR OBSTETRICAL INDICATIONS Lenita Wannmacher INTRODUCTION Cervical ripening, full‐term labour induction, and postpartum haemorrhage (PPH) are obstetric conditions that require proper and early interventions in order to save maternal and fetal lives. These interventions include pharmacological (uterotonic agents, mainly) and non‐pharmacological methods that have been tested and compared throughout the past decade. Regarding injectable uterotonic medicines (such as oxytocin, ergometrine, syntometrine, prostaglandins, and, more recently, carbetocin), factors limiting their use in low‐resource settings have been their cost, instability at high ambient temperatures, and difficult requirements of administration. In poor and rural settings, birth attendant skills are limited, transport facilities are inadequate, and injectable uterotonics and blood are hardly available. In contrast, misoprostol, a synthetic prostaglandin E1 analogue, presents low cost, storage at room temperature, and widespread availability. Misoprostol could also be easily administered by unskilled attendants or the women themselves, thus making them available for women giving birth at home or in isolated areas. These are benefits that make it particularly appealing for developing poor countries.1 Despite the built evidence of efficacy, induction of full‐term labour in women with a live fetus, as well as prevention and treatment of PPH, remains as a major challenge in modern obstetrics. Safety profile of misoprostol is still a matter of concern, especially relating to doses and routes used for the mentioned purposes.2 Misoprostol can be effectively administered vaginally, rectally, bucally, orally and sublingually. Pharmacokinetic studies have demonstrated the properties of misoprostol after various routes of administration. The rate of absorption varies considerably between routes, and care must be taken to use the correct dose and frequency for the specified route.
    [Show full text]
  • History Midwives Representing MANA Statistics Project the Profession Data Collection Form Alliance of Midwifery of North America Revision 2.0 – Page 1 of 8
    History Midwives Representing MANA Statistics Project the Profession Data Collection Form Alliance of Midwifery of North America Revision 2.0 – Page 1 of 8 Practice Code1 Y N Previous pregnancy and delivery history Midwife Code1 Number of previous: pregnancies Second Midwife Code1 (OPTIONAL) miscarriages5 Third Midwife Code1 (OPTIONAL) induced abortions Birth Code2 (MIDWIFE’S IDENTIFYING CODE) stillbirths5 live births Number of previous: History home births Client’s municipality: ___________________________ birth center births State or Province: ______________________________ Population: (CHOOSE ONLY ONE) caesarean sections | city | suburb | small town | rural VBACs Postal (ZIP) Code episiotomies Mother’s— postpartum hemorrhages age at booking Other previous pregnancy/delivery occurrences: last grade of high school completed gestation <37 weeks gestation >42 weeks post secondary formal education (YEARS) hypertension or pre/eclampsia6 3 Occupation : ___________________________________ breech Race/Ethnic origin: forceps/vacuum Caucasian IUGR/SGA7 African or Caribbean birth defect Native American shoulder dystocia Asian other: __________________________________ Hispanic none other4: _____________________________________ Mother’s height: (OR ESTIMATE) Special group: (CHECK ANY THAT APPLY) Amish feet inches OR Mennonite centimeters Francophone Mother’s prepregnancy weight: Immigrant of <10 years pounds OR kg Immigrant of >= 10 years Method of conception: (CHOOSE ONLY ONE) other group: ________________________________ | coitus Partner status
    [Show full text]
  • Florida Obstetric Hemorrhage Initiative (Ohi) Tool Kit
    FLORIDA OBSTETRIC HEMORRHAGE INITIATIVE (OHI) TOOL KIT A QUALITY IMPROVEMENT INITIATIVE FOR OBSTETRIC HEMORRHAGE MANAGEMENT Updated Version 10/2015 P a g e | 1 v. 10/2015 OHI Tool Kit Suggested Citation: Florida Perinatal Quality Collaborative (2015) Florida Obstetric Hemorrhage Initiative Toolkit: A Quality Improvement Initiative for Obstetric Hemorrhage Management. Acknowledgements: The FPQC gratefully acknowledges and thanks our partner organizations, including ACOG District XII, the Florida Chapter of AWHONN, the Florida Council of Nurse Midwives, the Florida Hospital Association, and the Florida Department of Health. The creation of this toolkit would not have been possible without the volunteer members of our Maternal Health Committee, including the members of the Obstetric Hemorrhage Advisory Team listed on page three of this toolkit, Washington Hill, MD and Karla Olson, as well as Kris-Tena Albers and Rhonda Brown from the Florida Department of Health. The FPQC would also like to thank the California Maternal Quality Care Collaborative, ACOG District II, and the Illinois Department of Public Health for sharing their materials, expertise, and time to assist the FPQC in the development of this Quality Improvement (QI) Initiative. This toolkit has been adapted and modeled from the California Improving Healthcare Response to Obstetric Hemorrhage Toolkit: The California Toolkit, IMPROVING HEALTHCARE RESPONSE TO OBSTETRICAL HEMORRHAGE, was developed through the California Maternal Quality Care Collaborative with leadership from the California Department of Public Health, Maternal Child and Adolescent Health (CDPH-MCAH), and is available through the California Maternal Quality Care Collaborative website: www.cmqcc.org/ob_hemorrhage. Funding for the development of the California toolkit was provided by: Federal Maternal & Child Health Title V block grant funding from the California Department of Public Health; Maternal, Child and Adolescent Health Division and Stanford University.
    [Show full text]
  • Medicalverdicts
    Medical Verdicts Notable judgmeNts aNd settlemeNts times she refused consent; her fam- Wrongful birth claim: Child has ily could not be contacted without her a chromosomal disorder authorization. Proper actions were A woman’S husband and an interpreter came to taken when consent was obtained. her first prenatal appointment at 10 weeks’ gesta- } VERDICT An Illinois defense verdict tion, as she spoke only Mandarin and the father’s was returned. English was limited. The ObGyn offered maternal serum sequential screening. At subsequent visits, Epidural pump stolen— with the husband and interpreter present, the mother saw a geneticist, genetic counselor, and nurse practitioner. At no time was additional while in use genetic testing offered. At the 23-week visit, the husband was present, but the interpreter had not yet arrived; the ObGyn attempted to communi- A WOMAN WAS GIVEN AN EPIDURAL cate through the husband. during labor. While she slept, a newly The baby was born at term with cri-du-chat syndrome. The child is hired physician assistant (PA) entered severely physically and mentally handicapped, and will require constant her room, disconnected the epidural medical and attendant care for life. pump, and stole it. The woman awoke but the PA assured her that every- } patient’S CLAIM The ObGyn did not offer amniocentesis or chorionic thing was fine. Soon, she experienced villus sampling (CVS), and failed to inform the parents that the chance significant labor pains and called the of a 37-year-old woman having a child with a chromosomal aberration nurses, who paged an anesthesiologist was 1.5%.
    [Show full text]
  • Antepartum Care
    Antepartum care (ch7) Preconception care: women’s health before pregnancy is really important, thus several models of preconception care have been developed … why we need it? - By the time the pregnant women have their first prenatal visit, it is too late to address and to reduce (how?? Our goals are assessing the risk + optimizing the health + medical intervention “in prenatal”) the risk of some birth defects like: Poor placental development (due to preeclampsia) low birth weight (<2500 grams) (seen in Preterm birth, and IUGR). * REMEMBER: Organogenesis begins early in pregnancy and placental development starts with implantation, about 7 days after conception. who7 days mostly after need conceptionit? - Women who are in high-risk are those with obesity, diabetes, or hypertension … etc. Preconception care in this type of women should be started 6 months to 1 year before conception is attempted. Examples of medical conditions: Affected by pregnancy: Affect the pregnancy: 1- SLE: 1- DM: Pregnancy should occur during disease quiescence, for less 6 months EGA The relationship between the hemoglobin If disease activate during pregnancy: adverse maternal and obstetrical A1C level and fetal malformation complication Risk: All SLE medication should be reviewed Hg A1c fetal Goal: maintain disease control with maximizing safety profile - Diabetic malformation 2- Hypertension: related fetal risk - Classification: malformation: Normal: Mild to moderate: 140- Severe: <7 Baseline CVS, CNS, <140/90 159/90-109 no benefit of >160/90 must 7.2-9.1 14% Gastric and treat it treat it 9.2- 23% genital - Treatment: methyldopa or labetalol 11.1 urinary, - Contraindication: ACE inhibitors, angiotensin II receptor blockers, direct >11.2 25% Skeleton renin inhibitors - Pregnancy risk: Superimposed preeclampsia, Placental abruption and Fetal - The relationship between the hemoglobin growth restriction.
    [Show full text]
  • 1 Postpartum Hemorrhage Hypothetical Case
    1 Postpartum Hemorrhage Hypothetical Case Studies Wisconsin Association for Perinatal Care Case 1: Identification and intervention 19-year-old G1 P0 female, admitted in active labor at 39 weeks with 3 cm dilatation after uncomplicated pregnancy. Patient has normal progress in cervical dilatation with a prolonged second stage requiring oxytocin augmentation and ultimately vacuum extraction (VE) delivery of a 4600-gram neonate. Placenta delivered within 5 minutes. Oxytocin was started by diluting 20 U in D5RL and running at 125 cc/hr. Patient passed large clots 20 minutes after delivery. BP 120/80, pulse 90. Uterus soft and up to the umbilicus. • Teaching points: o Atony vs. cervical/vaginal tear o Placenta inspected/complete? o Pelvic exam vs. uterine exploration vs. trail of carboprost (Hemabate®)? o When to type and screen Patient received 1 ampoule of carboprost every 15 minutes IM. Patient was typed and crossed. Patient was not examined. Oxytocin infusion was opened wide. Bleeding does not stop. BP 90/60, pulse 130. • Teaching points: o Dosing carboprost o Stepwise identification of bleeding source by OB exam o What blood products to order and in what amount o What other lab studies other than hematocrit o Response time: • Blood bank • Anesthesia • Surgeon Pelvic exam reveals bleeding from cervical os with no tears in cervix or vagina and “boggy” uterus. Clots expressed, patient “shocky.” BP 70/40, pulse 158. • Teaching points: o Treatment of shock o Oxytocic algorithm In spite of 6 ampoules of carboprost and IM methylergonovine (Methergine®), bleeding continues and there is “oozing” from IV site. • Teaching points: o Consumption coagulopathy and DIC o Rapid fluid and blood/blood component replacement o Surgical therapy o Timetable 2 Case 2: Identification and intervention 26-year-old G2P1 underwent cesarean at 11 pm for prolonged second stage and arrest of descent, after a 24-hour labor with dysfunctional labor, augmentation, and a 3-hour second stage.
    [Show full text]
  • UWOMJ Volume 74, No. 1 Western University
    Western University Scholarship@Western University of Western Ontario Medical Journal Digitized Special Collections 2005 UWOMJ Volume 74, No. 1 Western University Follow this and additional works at: https://ir.lib.uwo.ca/uwomj Part of the Medicine and Health Sciences Commons Recommended Citation Western University, "UWOMJ Volume 74, No. 1" (2005). University of Western Ontario Medical Journal. 5. https://ir.lib.uwo.ca/uwomj/5 This Book is brought to you for free and open access by the Digitized Special Collections at Scholarship@Western. It has been accepted for inclusion in University of Western Ontario Medical Journal by an authorized administrator of Scholarship@Western. For more information, please contact [email protected], [email protected]. Paediatrics London Health Sciences Centre 800 Cmnmissioners Road East London, ON N6A 405 v Canada's Trusted Choice Adverse Reactions Advene Drug Reection Overview MoA Common Adotetu Eft.cts I lodJ Syrtem I Clmetldlne (--.) ~D ('Mt) I<NS 1hood•"'• r-z.1-' ·' !Endocrtne end Het.bollsm - I I GJnecomerti• r- 0.3-4,0 I N/A [CedTolnt .. cttn•l - Wffi. Current drug information <•• ~~~~ at your fingertips! • Instant access to approximately 3000 Health-Canada-approved product monographs Updated and always current Search products by brand name, generic name and/or therapeutic class CANADLAN PHARMACISTS Search directories for Canada's poison control centres, various health organizations, ASSOCIATION manufacturers and distributors of pharmaceutical products ASSOCIATION DES PHARMACIENS DUCANADA • Printable, easy-to-read "Information for the Patient" leaflets - now the only resource offering these customer-friendly pages Subscribe online at www.e-cps.ca OMJ Volume 74 Number 1 Contents EDITORIAL Health Promotion Changes A Review of Current Literature on NuvaRing , Leanne Tran, Editor-in-Chief 3 a Contraceptive Vaginal Ring DEPARTMENT ARTICLES Michelle Ngo, B.Sc.
    [Show full text]
  • Post Partum Hemorrhage
    1/21/2019 Post partum Hemorrhage: Best Practices to Reduce Health Disparities LaShea Wattie M.Ed, MSN, APRN, AGCNS- BC, RNC-OB, C-EFM System Clinical Nurse Specialist, Perinatal 1 Objectives Improving Patient Outcomes • Promote equal access of evidence –based care practices • Discuss effective implementation strategies and tactics to improve clinician practice through Awhonn PPH project, OPS course. • Review best practice recommendations for TXA use in the OB patient in response to Postpartum Hemorrhage (PPH) • Discuss how to access resources and implement changes in your institution 2 1 1/21/2019 Magnitude of the Problem • Each year approximately 125, 000 women in the U.S. experience postpartum hemorrhage, its leading cause of PREVENTABLE death (Awhonn, 2014) • Every year there are 14 million cases of postpartum hemorrhage worldwide (USAID, 2010) • Estimated that 90% of PPH occurs within 4 hours after delivery. 3 5 2 1/21/2019 Standardization ▪ PATIENT SAFETY ▪ RISK REDUCTION ▪ SAFE CLINICAL OUTCOMES Processes ▪ ORDER SETS ▪ PROTOCOLS ▪ EDUCATION, PATIENT TEACHING ▪ DISPARITIES 6 7 3 1/21/2019 9 10 4 1/21/2019 Disparities Cultural Competency Fragmentation & Communication Literacy Bias Co-morbidities Inner-Institutional 11 Cultural Competency: Consider the Source • Cultural diversity officer • Text books : Are they current? Who was their source for obtaining the information? • Internet searches: Are you using a reproable website? • Breast pump rental example 14 5 1/21/2019 JOGNN IN FOCUS Continuing Nursing Education (CNE) Credit A total
    [Show full text]