Objectives

 Review the physiology of labor & delivery Precipitous Delivery  Review the basic equipment needed for a Are you prepared? successful emergency department delivery  Manage complications associated with Rachel Chin M.D. antepartum and intrapartum emergencies Associate Professor of Clinical Medicine San Francisco General Hospital UCSF School of Medicine

Physiology Physiology

 A ’s vital signs change  Heart Rate - increases 15-20 beats/min to during . an average pulse of 80-95 by 3rd trimester  Pressure  2nd trimester --> decreases to an avg of  Heart rate increases 102/55  decreases  3rd trimester --> increases to an avg of 108/67

1 Physiology What can possibly go wrong?

 Cardiac output increases 40%  PreEclampsia/Eclampsia  Stroke volume increases 25-30%  Vaginal  Plasma volume increases 45-50%  Previa, Abruption  RBC mass increases 33% but not as fast  Prolapsed cord as plasma volume  Malpresentation  Physiologic anemia  Breech, Limb, Face delivery  Slight respiratory alkalosis  Meconium staining  Premature delivery

Antepartum Emergencies Pre-eclampsia

after 24th week of gestation  Pre-eclampsia/ (Eclampsia)  New onset or worsening of chronic HTN  Vaginal Bleeding  5-7% of  Most often in first pregnancies  Other risk factors include young mothers, no , multiple gestation, lower socioeconomic status

2 Pre-eclampsia Pre-eclampsia

 Triad  Etiology?  Hypertension  “Disease of theories”   Abnormal endothelial fxn-cytokines (i.e., tumor necrosis factor ) and -1 

Preeclampsia-Searching for the Cause N Eng J Med 2004;350(7):641-642

Pre-eclampsia Pre-eclampsia

 Signs and Symptoms  Hypertension  Rapid weight gain  Systolic > 140 mm Hg  >3lbs/wk in 2nd trimester  Diastolic > 90mm Hg  >1lb/wk in 3rd trimester  Or SBP > 30 mmHg or DBP > 15mmHg above  Decreased urine output ’ patient s baseline BP  Headache, blurred vision  Proteinuria  Nausea, vomiting  1 + urine dip or >300 mg in 24 hrs  RUQ or Epigastric pain  Edema (particularly of face)

3 Pre-eclampsia Pre-eclampsia

 Complications  Management  Eclampsia  if term  Abruption  Premature separation of placenta  Consider if pre-term  or stroke  Lateral recumbent position  Renal failure  Hemolytic anemia  Bedrest   Lower blood pressure if SBP>170 or DBP>105  Hepatic hematoma/hepatic failure  Betamethasone if <34wks gestation  Retinal damage  Pulmonary edema  IUGR

Eclampsia Eclampsia

 Complications  Occurs in less than 1% of pregnancies  Same as pre-eclampsia  Signs, symptoms of pre-eclampsia  Maternal mortality rate: 10% plus:  Fetal mortality rate: 25% Grand mal seizures 

4 Question 34 year old 35 week pregnant female with no PMH BIBA for seizures. Found down  What is the best anti-convulsive treatment at home by husband, sz’ed twice in the for eclampsia? ambulance. C/o HA & epigastric pain  A. IV night prior. Paramedic report no head  B. IV trauma but ecchymosis on chest and  C. IV sulfate neck. VS: BP 200/116, HR 90, RR 16, 100% NRM, FHT 140’s. What do you do?

How should we treat Eclampsia seizures?

 Management

 Magnesium sulfate > phenytoin or  100% O2; assist ventilations, as needed diazepam  Left lateral recumbent position  MgSO4  6 gm IV bolus, then 2 gm/hr  10 gm IM if no IV access (5gm each buttock) Collaborative Eclampsia Trial  Betamethasone if <34 weeks gestation Lancet 1995 June 10;345:1455-63

5 Magnesium sulfate Magnesium sulfate

 Reduces risk of recurrent , maternal mortality and neonatal morbidity  4g IV loading dose over 15 minutes then 1-2 g/hr infusion  Mechanisms: potent vasodilator (against vasospasm) and NMDA receptor  Maintain serum concentration 4-7 mg/dL antagonist (neuroprotection) (when serum level is not readily available, infusion should be titrated to maintain “ ”  MgSO4 now on list of JCAHO-prohibited deep tendon reflexes) abbreviations  Maternal toxicity of magnesium is rare if drug is carefully administered & monitored N Engl J Med 2003;348:2154-2155.

Side Effects Your patient has been admitted for eclampsia and is receiving magnesium sulfate at 2gm/hr.  Drowsiness You assess that your pt’s respirations are 8 per min and you cannot elicit a reflex. What do  Flushing you do?  Diaphoresis  A. Discontinue magnesium & get a neurology  Hyporeflexia consult.  Hypocalcemia  B. Discontinue magnesium and administer O2  C. Discontinue magnesium and give O2 and 1 gm calcium gluconate IV.

6 Toxicity Antidote

 Absent DTRs (deep tendon reflexes)  Calcium gluconate  Ataxia  Calcium chloride- greater concentration   Respiratory

Magnesium sulfate Your eclamptic patient is approximately 2 hours out from her seizure. Labor induction is  First warning of toxicity is loss of DTRs (8- progressing successfully with now 6 cm 12 mg/dl) dilated. Her BP has been consistently elevated,  Somnolence (10-12 mg/dl) with the last 2 readings approx 165/110. Your choice for antihypertensive therapy is:  Slurred Speech (10-12 mg/dl)  a. methyldopa (Aldomet) 500mg PO  Muscular paralysis (15-17 mg/dl)  b. 5 mg IV  Respiratory difficulty (15-17 mgdl)  c. nifedipine 10 mg PO  (30-34 mg/dl)  d. 20 mg IV

Sibai BM, NEJM 1996;335(4):257-265 Treatment of Hypertension in Pregnancy

7 Hydralazine Labetalol

 Arterial vasodilator  Selective  and nonselective  antagonist  5 mg IV, then repeat 5 mg IV for 20 min up  20 mg IV, then 40-80 mg IV for 10 minutes to 20 mg total dose to 300 mg total dose  IV infusion 5-10 mg/hr titrated  IV infusion 1-2 mg/min titrated  Must wait 20 min for response between IV  Less reflex tachycardia and hypotension doses; possible maternal hypotension than with hydralazine

Abruption Abruption  Signs and Symptoms Premature  Mild to moderate vaginal bleeding separation of  But may have “concealed” bleeding at fundus placenta from  Continuous, knife-like abdominal pain  Rigid, tender uterus between contractions High risk groups:  High frequency, low amplitude contractions Older pregnant patients Hypertensives  Signs, symptoms of hypovolemia Multigravidas  Pre-eclampsia Trauma Cocaine

8 Abruption Abruption Third-trimester abdominal pain equals Hypovolemic shock out of proportion to Abruption until proven otherwise visible bleeding equals Abruption until proven otherwise

Abruption Placenta  Management Previa  100% O2  Left lateral recumbent position  Supportive care for hypovolemic shock Implantation of  OR if fetal distress placenta over cervical opening

9 Placenta Previa Placenta Previa

 Signs and Symptoms  Management  Painless, bright-red vaginal bleeding  Bedrest and “vaginal rest”  Classically after sex/vaginal penetration  If decompensating,

 Soft, non-tender uterus  100% O2  Signs and symptoms of hypovolemia  Left lateral recumbent position (proportional to blood loss)  Supportive care for hypovolemic shock  Cesarean delivery  May cause reflexive contractions (“irritability”)   Fetal distress Betamethasone if <34 weeks gestation

Labor

 Define it.  “It’s involuntary uterine contractions that Placenta Previa result in effacement & dilation of the cervix A vaginal exam should NEVER be and actual expulsion of the products of performed on a patient in the 3rd- conception.” trimester with vaginal bleeding until you know where the placenta

is located Rosen et al.

10 Stages of Labor History First Stage: Contraction & dilation  Is this your 1st baby?  When did your water break? Color?  Have you been receiving pre-natal care? Second Stage: Baby moves  Do you expect any complications? through  Are you currently taking any prescription birth canal & is born medication?  Have you been using any drugs or Third Stage: alcohol? Placenta delivered  Do you feel the need to push or have a BM?

Imminent Signs of Delivery Delivery

 Need to bear down or have a BM  Call for help  “I need to poop”  Peds, OB, NICU  Crowning  Warming unit, warm blankets  Rupture of  Contractions  1 to 2 minutes apart  Regular  Lasting 45 to 60 seconds

11 Basic Equipment Basic Equipment

 Sterile gloves  1 dozen 2” x 10” gauze sponges  Surgical scissors-1 pair  Baby blanket-1  Hemostats or cord clamps-3  Sanitary napkins  Small rubber bulb syringe  Plastic bag  Towels-5

Delivery Delivery

 Place gloved hand on • Control head and presenting part to support perineum prevent “explosive” • Slight downward delivery pressure to decrease pressure on urethra

12 Check the If the cord is around the neck, attempt to slip it over the baby’s head neck for the umbilical cord.

If it can’t be removed and if it’s tight, the cord must be clamped and cut.

Suction the Airway Suction the Airway

 On delivery of head, suction mouth then nose  Do not wait to suction if possible  Presumed large baby, “turtle sign”

13 Delivery Anterior Shoulder Delivery

 Gently guide baby’s head down to deliver anterior shoulder  Do NOT pull outward to avoid brachial plexus injury  Gently guide baby’s head up to deliver lower shoulder AFTER the anterior shoulder has cleared the pubic bone  Gently assist with delivery of rest of baby by elevating baby up off the perineum

Posterior Shoulder Delivery

14 Delivery Clamp, Cut Cord

 Control slippery baby during delivery  Support head, shoulders, feet Clamp about 4”  Consider delivering in the bed with patient on her side from baby  Keep baby’s head lower than feet to facilitate Second clamp 2” drainage of secretions from mouth further away from  Dry and stimulate baby first  Keep baby warm Cut between clamps

Delivery APGAR Score

 Bring warmer if available  Developed by Virginia Apgar  Flick baby’s feet, rub back to stimulate  Quick evaluation of infant’s pulmonary,  Do NOT shake infant cardiovascular, neurological function  Do NOT slap buttocks  Useful in identifying infant’s needing  “Blow-by” O2 if: resuscitation  Heart rate < 100  Persistent central cyanosis present  Resuscitate if necessary

15 APGAR Score Delivery of Placenta

Determine at 1 and 5 minutes postpartum!

Delivery of placenta can take up to 30 minutes. Don’t pull on the placenta, especially if preterm.

Placenta Maternal Care: Postpartum

 Check that  Palpate fundus after placenta delivered placenta appears  Examine perineum & cervix for laceration complete  Consider prophylactic Oxytocin before or  Check for trailing after placenta to decrease bleeding membranes,  20 units in 1L NS missing cotyledons  Place pad on perineum to help estimate bleeding

16 Maternal Care: Postpartum Uterine massage

 Excessive Bleeding  Oxytocin (Pitocin) 10 units IM after anterior shoulder or 40 units into 1 liter NS open wide  Methylergonovine (Methergine) 0.2 mg IM/PO qid prn  Contraindication: HTN or PreEclampsia/Eclampsia  Carboprost (Hemabate) 250 g IM  Contraindication: Asthma  Shock  IV, O2, Monitor  T & C

Shoulder Dystocia

 Wedging of anterior shoulder behind pubic Complicated bone  Impaction of the fetal shoulders and thorax Deliveries prevents adequate respiration and compression of the umbilical cord  Associated with post-term pregnancy, fetal macrosomia, mellitus, maternal obesity, and multiparity  Most can’t be predicted

17 McRobert’s maneuver Techniques

 Extreme lithotomy position with knees to  Check maternal position and make sure chest buttocks beyond bed or woman lying on  Moderate suprapubic her side pressure applied to  DON’T pull outward and try these abdomen by assistant maneuvers repeatedly while gentle downward traction is exerted on the fetal head

Techniques Breech Position

 Deliver the posterior arm  Wood’s corkscrew maneuver: 2 fingers into vagina and exerts pressure on fetal scapula, rotating posterior shoulder 180 in corkscrew fashion  Fracture clavicle (push out, not into lungs)

18 Care for Breech Presentation Care for Breech Presentation

 Place mother in same position as cephalic  Deliver one arm at a time delivery  Rotate shoulder anteriorly and sweep arm  Administer high-flow oxygen down  Deliver head by putting finger in baby’s face,  Allow delivery to occur spontaneously until make a “V” with index and middle fingers on foot, buttocks and trunk are delivered either side of baby’s nose to FLEX the head (support head)  DO NOT PULL BABY!!  Glide shoulders out of the birth canal

Management of with Care for Breech Presentation undelivered head.

 Suprapubic pressure may help flex baby’s head  Have someone else support the body in a towel  Prepare for neonatal resuscitation

19 Limb Presentation Limb Presentation

 Place mother in position that removes pressure from cord (head down or pelvis elevated)  Administer high-flow oxygen  Exert gentle pressure on baby’s body to prevent pressure on the cord (maintain this position en route to OR)  Get to the OR immediately

Prolapsed cord: Prolapsed Cord A condition in which the umbilical cord delivers through the vagina before any other presenting part.

The cord may be compressed between the baby’s head and wall of the birth canal, which prevents oxygen from reaching the baby.

20 Prolapsed Cord Prolapsed Cord

 Administer high -flow oxygen  Place gloved hand in vagina  Place mother in a position that removes  Apply gentle pressure upward on pressure from cord (head down or pelvis presenting part; relieve pressure on cord elevated)  If cord visible outside vagina, apply moist,  Encourage mother to blow/pant; don’t sterile dressings push during contractions  OR immediately with someone’s gloved hand in vagina

Management of Prolapsed Cord Premature Infants

 Definition  < 37 weeks gestation  Very low morbidity if >34 weeks

21 Premature Infants Conclusions

 Management  Delivery of the baby and placenta is a  Keep baby warm  Watch umbilical cord natural act that requires little assistance.  Keep airway clear for bleeding  Treat eclampsia with magnesium sulfate.  Assist ventilations if  Avoid contamination necessary  Treat HTN with hydralazine or labetalol.  Resuscitate if  3rd trimester abdominal pain = abruption necessary  Hypovolemic shock out of proportion to visible bleeding = abruption

Conclusions

 NEVER perform a vaginal exam on 3rd trimester bleeding in case of a Placenta Previa.  Never pull on the placenta.  Use McRobert’s maneuver for shoulder dystocia.  DO NOT pull a Breech Baby.  OR immediately for limb and prolapsed cord.

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