Dr. Fran Berard MD CCFP ASA April 2015 Dr. Fran Berard MD CCFP
No conflict of interest to disclose MD/89 CCFP/91 MB
23 years- Notre Dame de Lourdes-small rural francophone community
Small hospital Clinic ER PCH Teaching Obstetrics- PN care, emergency obs, low volume intrapartum care
Team: Rural nurses, 3 FPs sharing obs, Midwifery group Low risk obs is mostly uncomplicated but we focus on the worst case scenario
Pregnant women value the involvement of their FP
Pregnant women need caregivers close to home/ can be at risk if they have to travel
Providing intrapartum care makes me better at prenatal and emergency obs care
Basic interventions really improve outcomes in obstetrical emergencies https://www.youtube.com/v/NcHdF1eHhgc?v ersion=3&start=44&end=117&autoplay=0&h l=en_US&rel=0
MP Review diagnosis and management :
- Postpartum hemorrhage Anticipate / Prepare team
Early Identification
Mobilize team/ call for help
Early Intervention
Debrief and Document
=Better Outcomes Rachelle 30 yo G2P1 – in labor at term Rh+ GBS negative Previous uncomplicated vaginal delivery Uncomplicated prenatal course Admitted at 6 cm dilatation, progresses to fully dilated and pushing over the next 2- 3hours Baby now crowning Vertex delivers and then is sucked back against the perineum. The anterior shoulder does not deliver with the usual traction
The babys head does not restitute
WHO Reproductive Health Library Diagnosis?
Turtle sign
Shoulder dystocia What is it?
Anterior shoulder of baby impacted against the mothers symphysis pubis.
Death/Asphyxia of Baby
Fractures- Clavicle/Humerus
Brachial Plexus Injury
Maternal Post partum Hemmorhage
Maternal Uterine Rupture
Severe Perineal Tearing Incidence .3-5 %
Hoffman et al 2011 June
13200 births 2000 shoulder dystocias (1.5%) 100 =neonatal injury 36 brachial plexus injuries /clavicle fracture 5 neonatal encephalopathies 0 deaths 50%- NO RISK FACTORS
Big baby Post-term pregnancy > 42 weeks Multiparity Maternal diabetes mellitus Previous shoulder dystocia Previous big baby Excessive weight gain - more than 20 kg Maternal BMI > 50 - Ultrasound is not an accurate measure or predictor of macrosomia
Induction of labor for suspected macrosomia or diabetes does not prevent shoulder dystocia or brachial plexus palsy ***Assisted vaginal birth**- vacuum or forceps
Prolonged labor (maybe)
Induction of labor
Epidural anesthesia 1.Do not pull (on the head)
2. Push (on the fundus)
3. Panic
4. Pivot (severely angulate the head, using the coccyx as a fulcrum)
5. Do not cut a nuchal cord
Increase size of pelvic opening
Rotate the baby so the shoulders are in the oblique position
Reduce the width of babys shoulders - Notify your team
- Call for backup- who is that?
- Explain to mother and partner, coach etc and enlist their help
- Document time
Wait till next contraction after turtle sign - this does not alter fetal acidosis
Do not cut nuchal cord
Ask mother to stop pushing while doing internal maneuvers
Does not resolve the dystocia
Allows more room for internal maneuvers
Mediolateral
A 2011 retrospective study by Leung involving 205 cases:
Legs up- 25 % resolution
Legs up + Rotation or Posterior shoulder delivery=72% resolution
Legs up + Rotation + Post shoulder delivery= 94.6% resolution https://www.youtube.com/v/jsC9aUzx510?ve rsion=3&start=401&end=436&autoplay=0&h l=en_US&rel=0
WHO Reproductive Health Video Library Fracture clavicle
Zavenelli maneuver (cephalic replacement) followed by Csection Review possible interventions
Prepare the woman, her partner and the Team for Leg lift maneuver and the potential for rolling over
Placing a stool at the side of the bed corresponding to the fetal back to facilitate suprapubic pressure . Rachelles baby boy delivers with Leg lift ( McRoberts) and suprapubic pressure and responds well to stimulation
Post shoulder dystocia delivery care:
Cord gases Check baby and mother for injury Debrief with team including parents Document 1 Oxytocin 10 units IM or 5-10 units IV over 1-2 mins ( as long as no twin) (Misoprostol PO in low resource)
2 Controlled cord traction
3 Delayed cord clamping > 1 min
- Early breastfeeding - inspect placenta - cord gases Many cases- NO RISK FACTOR
Multiples, polyhydramnios, big baby
Rapid or long labor, Induction, High parity
Previous uterine surgery/ Previous PPH Review interventions for PPH
Discuss with team including patient and attendants
IV access
Plan IV Oxytocin 20-40 units in a litre NS after birth 1 hour postpartum-
Rachelle complains of feeling unwell and you are called back to see her
The nurses are concerned about the amount of vaginal bleeding
???? Post partum hemorrhage Definition : -500 ml blood loss in a vaginal birth
-Greater then 1,000 ml Csection
- any blood loss that has the potential to produce hemodynamic instability
- Less blood loss required with prexisting anemia occurs in 5% births worldwide
Leading cause of maternal mortality
Canada- 3.4 direct maternal deaths per million live births PPH requiring hysterectomy- 50 per 100000 hospital deliveries ( 2.5 per year if delivering 5000 babies per year) MILD< 20 % Diaphoresis Delayed capillary refill time Cool extremities Anxiety
MODERATE20-40 % Above plus: tachycardia Tachypnea postural hypotension Oliguria
SEVERE> 40% Above plus: hypotension agitation/confusion hemodynamic instability http://www.youtube.com/v/qYGLIX0lH8o?ver sion=3&start=54&end=90&autoplay=0&hl=e n_US&rel=0
Assess mother- VS, alertness, estimate amount of blood loss Attention- young women compensate well for blood loss
CAB- call for help
IV access- NS
Labs- CBC crossmatch, ? coag studies If placenta not out- may need manual removal
External uterine massage-check tone- remove clots
Empty bladder
IV Oxytocin 20-40units in a litre NS- run wide open T- Tone Uterine atony > 70%
T-Tissue- Retained tissue
T-Trauma Lacerations
T-Thrombin Coagulation disorders <1% Empty bladder
Bimanual compression
Exploration uterus- retained tissue
Second line drugs Trauma- inspect for laceration
Compress and repair
Thrombin –Consider coagulation issues Resistant bleeding Bleeding from other sites http://www.youtube.com/v/qYGLIX0lH8o?ver sion=3&start=1020&end=1098&autoplay=0 &hl=en_US&rel=0
Medical Aid Films Clip-17:30 Oxytocin running
Misoprostol ( Cytotec)
15-methyl prostaglandin F2 ( Hemabate or Carboprost)
Ergonovine Misoprostol (Cytotec) - off label
PO / SL works quickest –onset 30 mins lasts 2 hours Rectal- effect lasts longer-onset 40-60min lasts 6hrs
200mcg Po or SL +600mcg rectal or 400mcg PO or SL + 400 mcg rectal
Contraindications: allergy to PG Common sideffects: Abdominal pain, diarrhea, pyrexia 15-methyl prostaglandin F2α (fridge) (Carboprost/Hemabate) 250 micrograms IM Repeat as needed every 15 minutes max dose of 2mg (8 doses)
Common sideffects- Nausea, vomiting, diarrhea, hyperthermia,flushing, wheezing, coughing,nervousness
Asthma is a relative contraindication Ergonovine maleate- 0.2-0.25 mg IM or IV(slowly), repeat q2-4h IM or IV(slowly) as needed - max 5 doses
Contraindications: Hypertensive disorders of pregnancy -even if their BP normal currently Certain HIV drugs
Adverse effects: Nausea, dizziness, hypertension Ongoing bleeding inspite of meds:
Tamponade- Bakri balloon
?Tranexamic acid ( risk of thrombosis)
Invasive interventions-
Embolization Laparotomy Emergency hysterectomy
Bleeding resolves with Oxytocin IV and massage and Misoprostol
Followup care- -Debrief with team and mother and supports -FU Hgbs and iron -Document Holland, Anne ; Rubeo, Zachary ; Flood, Karen ; D'Alton, Mary 2013 Shoulder dystocia maneuvers and neonatal outcomes American Journal of Obstetrics and Gynecology, 2013, Vol.208(1), pp.S136-S136
Leung TY, Stuart O, Suen SS, Sahota DS, Lau TK, Lao TT. Comparison of perinatal outcomes of shoulder dystocia alleviated by different type and sequence of maneuvres: a retrospective review. BJOG 2011;118(8):985-90.
http://www.pitterpatter.com.my/shoulder-dystocia/ slide 14 picture More OB Chapters on Shoulder Dystocia and Postpartum Hemorrhage
World Health Organization Reproductive Health Library http://apps.who.int/rhl/videos/en/index.html
Medical Aid Films http://medicalaidfilms.org/our- films/emergency-obstetric-newborn-care- skilled/?v=72407733 http://emedicine.medscape.com/article/275 038-overview#aw2aab6b2b5
Shoulder Dystocia Copyright © 2004 - 2015 Dr. Henry Lerner http://shoulderdystociainfo.com/index.htm Active management of the third stage of labour: prevention and treatment of postpartum hemorrhage –SOGC guideline
235 - Published October 2009 Principal Authors
Vyta Senikas, Dean Leduc, André Lalonde