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 : - Shoulder Dystocia - 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 Symphysiotomy 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.