10/28/2019

Obstetrical Emergencies

Kenneth W. Merkitch Jr. M.D.

Disclosure

• No financial interests to disclose

Objectives

• Differentiating false versus true labor • Preterm labor‐ management considerations • prolapse: Diagnosis and management • Antepartum hemorrhage: and management considerations • Postpartum hemorrhage: Diagnosis and management • in : Differential diagnosis and management considerations • : Diagnosis and management • Breech delivery: Management • : Diagnosis and management

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If I Teach You One Thing Today, I Hope It is This… •In a women of reproductive age (10‐60) who presents with or irregular vaginal (or both), what should you always consider/order??

Nobody Has Ever Regretted Ordering a …

Preterm Labor and Delivery

• Accounts for 10+% of all deliveries • ‐ yes, we use them, but they don’t really work… most common are , nifedipine and indomethacin • Patient in active preterm labor‐ most important things that could/should be done prior to transport are administering antenatal corticosteroids (helps accelerate baby’s lung maturity‐ Betamethasone 12 mg IM, repeated in 24 hours) and ampicillin (2 gram loading dose‐ helps prevent neonatal Group B streptococcal sepsis) • If ruptured membranes suspected‐ avoid digital exam of (shortens latency period from rupture to delivery)

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Ruptured or Not?

Labor or Not?

• False labor • Contractions at irregular intervals • No change in interval, remain spaced • No cervical dilation • True labor • Contractions occur at regular intervals • Shortening of interval with increased intensity • Cervical change

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Obstetrical Emergencies- • Frequency: 1 in 161‐714 deliveries • Risk Factors: Any condition that results in a “poor fit” between and cervix‐ more common preterm, small babies breech presentation, anomalies, multiple gestation, grand multiparity

Umbilical Cord Prolapse- Diagnosis

• Palpable umbilical cord below presenting part • FHR abnormalities‐ severe/repetitive variable decelerations or (with complete occlusion) prolonged deceleration/

Umbilical Cord Prolapse- Suggested Management • Trendelenburg position • Have someone keep presenting part elevated • Maternal oxygen • Terbutaline 0.25 mg IV or subq (tends to last 30‐60 minutes‐ may repeat if contractions begin to return or transport takes that long). Will make patient feel jittery/raise pulse. • Place foley/fill retrograde with 500‐700 cc saline • Proceed rapidly to cesarean section when possible

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Antepartum Hemorrhage- Potential Causes • Active labor • Abruption‐ Risk factors include previous history, tobacco use, cocaine or meth use, , previous C/S, low , grand multiparity • previa‐ Risk factors include previous C/S, grand multiparity, increased maternal age, tobacco use

Antepartum Hemorrhage- Management

• AVOID DIGITAL CERVICAL EXAM UNLESS YOU ARE CERTAIN OF PLACENTAL LOCATION! • Large bore IVs, maternal oxygen, maternal tilt to left (why?), rapid transport to hospital (if preterm‐ tertiary care center)

Seizures in Pregnancy

• What is in your differential?

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Seizures in Pregnancy • Pre‐existing disorder • Maternal drug use • oRisk factors: previous history preeclampsia/eclampsia, pre‐existing HTN, multiple gestation, first baby (why?) oSigns/symptoms: headache, visual changes, epigastric pain, elevated BP, , , low platelet count, elevated LFTs

Seizures in Pregnancy- Suggested Treatment • Supportive care: maternal oxygen, IV fluids (careful not to bolus too rapidly if eclampsia suspected, as renal function may be poor), maternal tilt to left, Foley • If eclampsia suspected: consider magnesium 6 grams over 30’‐ then 2 grams/hour. Rough guide‐ urine output <25 cc/hr stop magnesium, 1 g/hr in 26‐50 cc/hour, 2 g/hr if 51‐100 cc/hr, 3 g/hr if >100 cc/hr • Anti‐hypertensives for systolic BP >160 or diastolic BP >105‐ 20 mg IV or 5 mg IV • Transport

Postpartum Hemorrhage • Occurs in 5% of deliveries • most common cause (risk factors‐ overdistended , induced/ augmented labor, prolonged 3rd stage, previous hx PPH, placental management at C/S, having had 5 or more previous children, red hair), with retained placental fragments and vaginal/cervical lacerations accounting for most of the rest (atony accounts for >80%)

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Causes of Postpartum Hemorrhage- The 4 Ts

• Tone‐ soft, boggy uterus • Trauma‐ genital tract lacerations, uterine inversion • Tissue‐ retained placental tissue (inspect placenta for missing cotyledons after every delivery) • Thrombin‐ defects

Active Management of Third Stage: Helps Decrease Loss at Delivery

• with or soon following delivery (can be given IV‐ 40 Units in a liter given at 500 cc/hour, or IM‐ 10 Units) • Controlled cord traction (this may be hard for people who don’t do deliveries to have a feel for and may not be that important) • Uterine massage after delivery of the placenta

What are we seeing in progress here?

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Uterine Inversion • Why one should never tug too hard on a placenta that has not shown signs of separation! • Incidence: 1/2000 deliveries • Do not peel off placenta if still attached‐ administer uterine relaxant (nitroglycerin 100 mcg very helpful), re‐ invert uterus and, with hand in place, administer vigorous oxytocics‐ of course, T+C, Large‐bore IVs for fluid replacement, Anesthesia notification • Re‐version may require ‐ pulling up on inverted corpus with Babcock or Allis forceps to reestablish normal anatomy, or even incising cervical ring posteriorly to allow this • Hemorrhage common

Breech - Risk Factors • Preterm labor/delivery (~50% of babies breech at 28 weeks, 3% at term) • Fetal anomalies (what is the reason most babies are vertex at term?) • Abnormal uterine shape (e.g. bicornuate, septate, myomata) • Previous history

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Breech Vaginal Delivery

• If frank breech‐ once buttocks come out, bend knees and gently sweep legs out of by feet

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Breech Vaginal Delivery

• If frank breech‐ once buttocks come out, bend knees and gently sweep legs out of vagina by feet • Once legs/buttocks out, wrap body in towel; have mother push (avoid excessive traction on fetus!) until scapula visible

Breech Vaginal Delivery

• If frank breech‐ once buttocks come out, bend knees and gently sweep legs out of vagina by feet • Once legs/buttocks out, wrap body in towel; have mother push (avoid excessive traction on fetus!) until scapula visible • With scapula visible‐ reach up along body, grasp humerus on either side and sweep down along fetal body/out of vagina • What do you do if arms up too high to do this?

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Breech Vaginal Delivery

• Nuchal Arms (arms well above head in breech presentation): Rotate body away from arm you want to try to deliver‐ will help open up room to get access to arm

Breech Vaginal Delivery • Nuchal Arms (arms well above head in breech presentation): Rotate body away from arm you want to try to deliver‐ will help open up room to get access to arm • Delivery of Head: Mauriceau‐Smellie‐Veit maneuver‐ Place index and middle fingers of one hand over maxilla, with fetal body resting on forearm; an assistant should provide suprapubic pressure to keep the head flexed while you use your other hand to grasp neck and shoulders and provide gentle downward traction. As suboccipital region appears under symphysis, elevate body of fetus towards maternal ‐ this will result in mouth, nose, brow and last occiput emerging from perineum.

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Obstetrical Emergencies- Shoulder Dystocia Risk Factors • Previous history • (Type1, Type 2, Gestational) • • Post‐dates • Higher parity • History of large children

Shoulder Dystocia- General

• Mechanism: Impaction of anterior shoulder behind the maternal • Definition: Any delivery that requires additional maneuvers following the failure of gentle traction on the fetal head to deliver the shoulders? Any delivery in which the head‐>body delivery interval is >60 seconds? No absolute, agreed‐upon definition. • Incidence: 0.6‐1.4% • Goal of preventing and/or managing shoulder dystocia: Avoiding permanent or other serious neonatal injury

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Shoulder Dystocia- Maneuvers • Suprapubic (NOT FUNDAL!) pressure‐ requires just one assistant. Maintain a small footstool in each delivery room for this purpose • Rubin’s maneuver: Rotation of shoulders off midline to approximately 30 degrees

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Shoulder Dystocia- Maneuvers • Suprapubic (NOT FUNDAL!) pressure‐ • Rubin’s maneuver: Rotation of shoulders off midline approximately 30 degrees •McRoberts maneuver‐ needs two assistants‐ flexion of legs sharply on the abdomen; this causes straightening of the sacrum relative to the lumbar vertebrae and rotation of the pubic symphysis towards the maternal head, the latter of which helps free the impacted anterior shoulder

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Shoulder Dystocia- Maneuvers • Suprapubic (NOT FUNDAL!) pressure‐ • Rubin’s maneuver: Rotation of shoulders off midline approximately 30 degrees •McRoberts maneuver‐ needs two assistants‐ flexion of legs sharply on the abdomen • Delivery of the posterior arm • Flex posterior arm at elbow and draw it across fetal chest and out perineum; this changes a bisacromial diameter to an axilloacromial diameter (on average, 2 cm shorter) • If unable to reach posterior arm‐ hook fingers, or IV tubing, in posterior axilla to bring posterior shoulder/axilla down, then deliver posterior arm

Shoulder Dystocia- Maneuvers

• Suprapubic (NOT FUNDAL!) pressure‐ • Rubin’s maneuver: Rotation of shoulders off midline approximately 30 degrees •McRoberts maneuver‐ needs two assistants‐ flexion of legs sharply on the abdomen • Delivery of the posterior arm • Woods corkscrew maneuver: 180 degree rotation of posterior shoulder to anterior, dis‐impacting anterior shoulder from under symphysis.

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Shoulder Dystocia- Maneuvers

• Suprapubic (NOT FUNDAL!) pressure‐ • Rubin’s maneuver: Rotation of shoulders off midline approximately 30 degrees •McRoberts maneuver‐ needs two assistants‐ flexion of legs sharply on the abdomen • Delivery of the posterior arm • Woods corkscrew maneuver •Have patient go on all fours • Clavicular fracture‐ Can be difficult to do on purpose • : Cephalic replacement with C/S‐ last resort

Shoulder Dystocia- Simulation Training • Draycott et al, Obstet and Gynecol 2008; 112:14‐20: Looking at cases of shoulder dystocia simulation training resulted in the following improvements in care: • No recognized maneuvers (e.g. McRoberts, suprapubic pressure, Rubins) performed decreased from 50.9% to 8.0% (p<0.001) • “Excessive” traction documented: 16.7% to 9.2% (p=0.010) • Neonatal injury: 9.3% to 2.3% (RR 0.25, 95% CI 0.11‐0.57)

Ob-Gyn Emergencies Cheat Sheet

• ALWAYS order a pregnancy test in women presenting with abdominal pain and/or abnormal bleeding who are of reproductive age • Although risk factors (previous ectopic, history of pelvic inflammatory disease, history of , long‐standing , current IUD use) do increase the chance of , 50% of women who present with an ectopic pregnancy do not have a risk factor • By B‐HCG level of 3500, one should see an intrauterine pregnancy on ultrasound • Umbilical cord prolapse‐ if at a site remote from delivery, do the following • Elevate presenting part digitally (fingers, not by computer!) • Steep Trendelenburg • Terbutaline 0.25 mg IV to stop contractions‐ may repeat every 30‐60’ as needed • Place foley/fill bladder retrograde with 500‐700 cc saline • Pregnant women presenting with heavy bleeding‐ do not check cervix until you are certain of location of placenta (could be a previa‐ placenta covering cervix‐and exam will result in heavier bleeding). Treatment • Large‐bore IVs • Left maternal tilt • Transport

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Ob-Gyn Emergencies Cheat Sheet

• Seizures in pregnancy: In absence of known seizure history, most likely eclampsia • IV magnesium: 6 grams over 30” • If significantly hypertensive (systolic >160 and/or diastolic >105), administer either labetalol 20 mg IV or hydralazine 5 mg IV • Transport • Postpartum hemorrhage: After delivery, administer Oxytocin either 10U IM or 20‐40 U/liter‐ 1000 cc/hour • Shoulder dystocia: Anterior shoulder stuck behind symphysis‐ more common with obese mothers, larger babies, maternal diabetes, previous shoulder dystocia, but ~50% occur in absence of risk factors. Maneuvers • Rotate shoulders 30 degrees off midline • Flex maternal legs on maternal abdomen and rotate outwards • Strong suprapubic pressure • Deliver posterior arm • Breech delivery • Once buttocks present, bend knees and sweep out • Do not pull on baby’s body‐ allow spontaneous delivery to axilla • Sweep arm along body‐ may rotate body away from arm you are trying to deliver to allow better access to arm • Place hands along top of head and face and flex head/deliver

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