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 woman’s vital signs change Heart Rate - increases 15-20 beats/min to during pregnancy. an average pulse of 80-95 by 3rd trimester Blood Pressure 2nd trimester --> decreases to an avg of Heart rate increases 102/55 Blood pressure 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 bleeding Plasma volume increases 45-50% Placenta 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
Hypertension after 24th week of gestation Pre-eclampsia/Seizures (Eclampsia) New onset or worsening of chronic HTN Vaginal Bleeding 5-7% of pregnancies Most often in first pregnancies Other risk factors include young mothers, no prenatal care, multiple gestation, lower socioeconomic status
2 Pre-eclampsia Pre-eclampsia
Triad Etiology? Hypertension “Disease of theories” Proteinuria Abnormal endothelial fxn-cytokines (i.e., tumor necrosis factor ) and endothelin-1 Edema
Preeclampsia-Searching for the Cause N Eng J Med 2004;350(7):641-642
Pre-eclampsia Pre-eclampsia
Signs and Symptoms 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 Labor induction if term Abruption Premature separation of placenta Consider if pre-term Cerebral edema or stroke Lateral recumbent position Renal failure Hemolytic anemia Bedrest Thrombocytopenia 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 Coma
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 phenytoin night prior. Paramedic report no head B. IV diazepam trauma but ecchymosis on chest and C. IV magnesium 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 seizure, 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 Pulmonary edema Respiratory paralysis
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 cervix 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. hydralazine 5 mg IV Respiratory difficulty (15-17 mgdl) c. nifedipine 10 mg PO Cardiac arrest (30-34 mg/dl) d. labetalol 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 uterus 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 Fetal distress 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 amniotic sac 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 shoulder dystocia 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, diabetes 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 breech birth 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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