building a healthy community low risk obstetrics session 2 birthing suite & puerperium dr....

BUILDING A HEALTHY COMMUNITYBUILDING A HEALTHY COMMUNITY

Low Risk ObstetricsSession 2

Birthing Suite & Puerperium

Dr. Kristine Whitehead

2015


Objectives

• Able to diagnosis and manage early labour

• Able to practice active management of labour, including augmentation

• Prepare for expected procedures: ARM, fetal scalp electrode, SVD

• Able to provide early postpartum care


Spontaneous vaginal delivery

• video


Management of Labour

• Your main responsibility on this rotation

• Respect labour, do not fear labour

• Active management is practiced at TOH


Definition of Labour

• Regular, Frequent Contractions

PLUS

• Cervical Change (Dilatation and Effacement)


Definition of Labour

• Must diagnose labour correctly

• Otherwise can not diagnose labour dystocia


Stages of Labour

First Stage A. Latent phase

- up to 3-4 cm in primip, 4-5 cm in multip

B. Active phase - more rapid cervical dilatation

- follows latent phase

- ends with full cervical dilatation


Second Stage• A. Early period is from full dilatation to +2 or

urge to push• B. Second component is marked by maternal

expulsive effort • lasts until delivery of fetus


Third Stage• Delivery of placenta


Normal Labour - FriedmanHistorical data were collected before the widespread use of

epidural analgesia

Second stage values must be modified to reflect this Nulliparous Multiparous

Latent Phase Mean (time) Longest normal

6.4h 20.1h

4.8h 13.6h

Active Phase Mean (rate) Slowest normal

3.0cm/ h 1.2cm/ h

5.7cm/ h 1.5cm/ h

Second Stage Mean (time) Longest normal

1.1h 2.9h

0.4h 1.1h


1969 O’Driscoll

• Active management of labour

• To prevent primips from labouring >24 hrs

• Objective to decrease C/S rate


O’Driscoll’s methods

• Only admit in true active labour

• ARM on admission

• Midwife to “monitor the labour and encourage the mother”

• 1 cm/hr or oxytocin titrated to achieve 5-7 contractions q15mins


Results

• C/S rate increased from 4% to 9%

• 40% women required oxytocin

• 12X increase in epidural analgesia

• Cochrane review: only continuous psychological support in labour lowered the C/S rate


• Labor seems to progress more slowly now than in the 1950s

• Mean duration active labor 4.6 hrs. in 1950-60’s

• Mean duration active labor 8 hrs. in 1980-90s

• WHY?


What’s different?

• Mean body mass higher (BMI)

• Increased fetal size

• Increased maternal age

• Obstetric management eg. Induction, oxytocin, epidural, continuous monitoring


Normal Labour

• 90% women who have successful vaginal birth progress >1cm/hr after 5cm cervical dilatation

Peisner DB, Rosen MG: Transition from latent to active labor. Obstet Gynecol 68:448, 1986.


Normal Labour - Partogram

• Used routinely in caseroom

• Nurse starts plotting when (and only when) in labour

• to follow progress of labour and descent of presenting part


Labour Dystocia

• Definition

>4 hrs of <0.5 cm/hr dilatation (< 2 cm dilatation in 4 hrs.)

or

>1 hr of no descent during active pushing


Labour Dystocia - DiagnosisMost common reasons for non-elective c-

section (LSCS):

1) labour dystocia/failure to progress – 30%

2) non-reassuring FHR tracing – 22%

3) Malposition/malpresentation – 12%

4) Breech – 9%


Labour Dystocia - Diagnosis

Therefore…

Must diagnose dystocia correctly to reduce number of inappropriate C/S

WHAT CAN GO WRONG?


Labour Dystocia - 3 “P’s”

• POWER - hypotonic contractions

- uncoordinated contractions

- weak maternal expulsive

effort



• PASSENGER fetal position

fetal attitude

fetal size

fetal abnormalities

(e.g. hydrocephalus)



• PASSAGE bony pelvis soft tissue

(full bladder/rectum)


Labour Dystocia - 3 “P’s” +

• Person - the woman (her beliefs, preparation, knowledge & "capacity" for doing the work of labour & birth

• Partner - her support & his/her knowledge, beliefs & preparation

• People – the others involved



• Pain – impact of experience of pain & socio-cultural beliefs/environment on capacity for coping

• Professionals – how the health care team supports, informs & collaborates in care & share info with the woman & her partner



• Patience – difficult to be passive

• Peripherals - reasonable privacy, quiet, adequate accessories for labour and delivery (functioning birthing beds, lights, birthing balls, hot water, mirrors, linens)


How can we prevent dystocia?

• Accurate diagnosis of labour

• Management of latent labour

• Prepared childbirth (e.g. classes)

• Birthing companion (e.g. doula) & consistent nursing

• Ambulation (?) – Cochrane review 2009


Continuous Intrapartum Support(RN, family/friend, doula)

• Greatest benefit for vulnerable populations• Compared to limited support as control• Benefits: shortened duration of labour, increased

SVD, fewer epidurals, less oxytocin, fewer AVD/C-sections, greater patient satisfaction

• Continuous labour support from labor attendant for primiparous women: a meta-analysis. Zhang et al, Obstet Gynecol 1996


How do we manage dystocia?

• ARM• Oxytocin augmentation• Therapeutic rest with analgesia• Repositioning of patient• Empty bladder

If dystocia persists, then consider Dx CPD and proceed to delivery


ARM

• Routine ROM does not accelerate spontaneous labour – Cochrane 2007, reviewed 14 RCTs

• Insignificant shortening of first and second stage, both primips and multips

• Does reduce need for oxytocin• Does not increase maternal infection or epidurals

• Cochrane 2009, review 12 RCTs, shortened labor by 1.11 hrs if ARM + pitocin in prolonged labor


ARM

• Amniotomy for shortening spontaneous labour. Smyth RM, Markham C, Dowswell T. Cochrane Database Syst Rev. 2013 June;6:CD006167

• ? More FHR tracing abnormalities afterwards

• Intervention for dystocia, not for prevention


Indications for ARM

• Assess for meconium• Application of fetal scalp electrode• Insertion of IUPC• Prior to initiation of oxytocin, to augment labor

• Consider presentation first (ensure cephalic)• Commits you to delivery• Ensure explicit consent


Technique ( ↓ risk of cord prolapse):

1. Avoid dislodging fetal head

2. Fundal pressure/suprapubic pressure

3. ARM during contraction

4. Head is preferably engaged (station = 0)


Photos - amnihook

• practice


Contraindications to ARM

• Unengaged presenting part - absolute

• Relative - Polyhydramnios

• Relative - Hepatitis B/C or HIV, GBS not on ABs


Augmentation of labor

• Low dose vs. high dose protocol

• Risks and benefits: must have informed consent

• Properties of pitocin


Oxytocin/pitocin

• Receptors in myoepithelial cells of breast, myometrium, decidua

• Causes rhythmic contractions of myometrial smooth muscle at low dose

• 8-10 mU/min infusion gives same clinical response found in spontaneous labour

• Hypotension possible with bolus iv admin

• Antidiuretic activity – water intoxication possible with high-dose (> 40mU/min)

• Half-life appx 5 mins


Oxytocin/Pitocin

•Low dose protocol – less hyperstim, smaller overall dose•High dose protocol – more hyperstim but no increased maternal/neonatal morbidity, may shorten labour and lower C/S rate (2010 meta-analysis of RCTs)•Potential risk of fetal compromise with hyperstim•Tiny risk of uterine rupture, water intox


Persistent dystocia

• True CPD (craniopelvic disproportion) management = c-section

• Most CPD is relative so try other maneuvers first


Second Stage Management

• Debate exists re. setting time limit in the absence of fetal compromise

• Woman should not be encouraged to push unless she feels the urge

• Non-directed pushing in NCB



• Generally, prolonged 2nd stage occurs at :

Primip 3 hr with epidural

2 hr without epidural

Multip 2 hr with epidural

1 hr without



• Ottawa Hospital uses In-House Clinical Practice Guidelines (CPG’s), see myHospital

• Categorized

= Primip with and without regional anesthesia

= Multip with and without regional anesthesia


Third Stage Management

• Active management of the third stage should be offered, since it reduces incidence of PPH due to uterine atony

• This includes: oxytocin, controlled cord traction, uterine massage after delivery of placenta

• Active management of the third stage of labour: prevention and treatment of postpartum hemorrhage – SOGC Oct. 2009


Active Management of the Third Stage

• Signs of Separation– Gush of blood– Lengthening of umbilical cord– Anterior-cephalad movement of fundus– Firm, globular fundus


Active Management of the Third Stage

• Active Management– Early cord clamping (no longer recommended)– Controlled cord traction– Uterotonic agent: oxytocin vs. duratocin– Know dose and route, order prior to delivery


Delayed Cord Clamping

• Benefits: elevated hematocrit/ferritin up to 6 months, less anemia at 3-6 months

• Increased asymptomatic polycythemia• ? Increased neonatal jaundice requiring

phototherapy• See myHospital for policy and procedure • Late vs. early clamping of the umbilical cord in full-term neonates: systematic review

and meta-analysis of controlled trials: Hutton, EK et al, JAMA 2007 Mar 21


Management of Labour - Case

• Phillipa 28 y.o. G1P0 EGA = 39+5 weeks• Presents at 1700 to triage• Contraction q 7-10 min since last night• More frequent this afternoon x 1.5 hours• Very uncomfortable

• What do you need to know?• V/E -


1 cm dil, 2 cm long, stn – 2

FHR = 155 bpm, + accels, no decels on IA

Your assessment?

What is your management?


• She goes home with nubain 20 mg IM

• Rest/sleep, returns at 0200 - contractions now q3-4min

• Uncomfortable - wants to “go natural”

• What do you need to know?

• V/E -


4 cm dil., thin (1/4 cm), cephalic, intact

FHR normal, 140-145 bpm, + accels, no decels

Your assessment?

What now?


• Uses shower/tub

• V/E 4 hrs later (0600)


• Cx = 5 cm, station -1

• FHR normal

Assessment?

Management? She has many questions about the epidural


Epidural

• See info sheet in each room

• Informed consent – from anesthesia

• Risks – sytemic toxicity, high spinal, hypotension, inadequate or failed block, pruritis, N and V, resp depression, spinal HA, backache, infxn, PP neuropathy

• ? Prolonged labour, increased AVD/CS


• Epidural inserted 0700

Now what?

Do you need continuous EFM?

When to reassess?

Next exam -


• V/E at 0900: 8 cm, station -1• Bulging membranes, head well applied• FH shows frequent variable decelerations• FHR - baseline 145 bpm, acceleration with

scalp stim• Comfortable but contractions spacing out to

q4-5 mins• T = 37.7 C

Assessment? Management?


• Successful ARM for abundant clear liquor

• Over 30 mins. contractions increase to q2-3 mins.


• V/E at 1100 hr: Fully / station 0

• FH - occasional uncomplicated variable decels

• Uncomfortable with contractions, especially in her back

What do you do?


• Top-up the epidural

• Frequent postion change

• RN empties her bladder

• Re-assess in 1 hour as per protocol


• V/E at 1200: fully dilated, stn 0, prominent anterior lip

• RN wonders re. OP?, wants OB resident to check

• Contr q3-4min X 45 sec

• FHR normal

• Comfortable with epidural

Management plan?


• OBS Resident advises you to call your staff

• Staff confirms position is LOA

• Oxytocin started

• Repositioned to knee-chest

• Staff returns briefly to office, near by

• RN wants scalp electrode

What now?

When to recheck?


Fetal scalp electrode

• Technique: see instructions with packaging

• Risks – superficial scalp trauma, infxn

• Benefits – accuracy, consistency of FHR

• Must have informed consent


• V/E at 1300 (one hour later): spines +3

• Urge to push

Plan?


• Start pushing!!

• Call staff back


• FH shows prolonged deceleration to 60 bpm x 3 minutes at 1400

• Presenting part can be seen easily with pushing


• OB staff present, supervises your vacuum delivery (FM staff coming up the elevator)

• Baby boy 4050 g delivered over 2 pulls, no pop-offs

• Neonates in attendance• Apgars 9,9

What are the important issues here?


Summary - Management of Dystocia

• ARM• Oxytocin augmentation• Therapeutic rest with analgesia• Repositioning • Empty bladder• Always assess maternal and fetal wellbeing

If dystocia persists, consider CPD/FTP and proceed to operative delivery


• Break

• Practice simulation: ARM, scalp electrode


Delivery Room

• PPH prophylaxis• Neonatal resuscitation prn• Delayed cord clamping• Possible cord blood collection• Skin-to-skin benefits

– Temperature, HR, respirations– Glucose– Breastfeeding

• Epidural removed, catheter prn, vitals, iv• Shower, teaching by RN


A4/8E

• PP orders

• Vitals, care map assessment

• Breastfeeding on demand, rooming in

• LC, SW, DPH prn

• Vaccination (MMR, influenza), Rhogam prn

• Discharge planning


Early Maternal Issues• After pains• Engorgement: milk, edema• Urinary retention: protocol, pudendal nerve injury• Hemorrhoids• Musculoskeletal pain• Headache• DVT: 21-84 times more common for 2/52 PP• Anemia


Case #1 • 23 year old G2P2, healthy

• SVD, healthy girl, epidural

• Second degree perineal tear

• PPD # 1 - slightly tender uterine fundus, some breastfeeding trouble

• PPD # 2 – T = 38.0 deg C

• What do you do?


Postpartum EndometritisPresentation

• Fever +/- chills

• Tenderness, pain - uterus

• Lochia may be foul, heavier bleeding


Postpartum Endometritis

• Polymicrobial: anaerobes and aerobes

• Potentially lethal: esp GAS, clostridium

• Both cause toxic shock syndrome


Postpartum EndometritisTreatment

• Clindamycin and Gentamicin iv

• Clindamycin po

• Doxycycline and Metronidazole

• Clavulin


• Breastfeeding problem ie. Pain, weight loss, hungry baby

• Risk of dehydration, xs wt loss >10%

• ? Risk of pacifier

• ? Risk of formula

• ? Risk of PPD


Case #2• 37 year old G1P1• C-section, healthy boy, epidural• Day 2 : tender nipples, 8% weight loss, fussy baby• Tearful Mom, mother-in-law rocking baby with a

pacifier

• Is this all normal?


Management

• Support/encourage/teach +++

• LC consult

• Start hand expression, pumping


Case #3

• 30 year old G2P2

• SVD, healthy girl

• First degree tear

• Increasing perineal pain on day 2

• Is this normal?

• What should you do?


Case #4

• 32 year old G4P4

• Day 2 : exhausted, lethargic, new Canadian

• History of depression

• Limited supports

• Is there anything you can do to help?


• Assess supports

• SW consult

• PHD referral/HBHC – request early visit


QUESTIONS/COMMENTS

building a healthy community low risk obstetrics session 2 birthing suite & puerperium dr....

Documents