Induction of labor, etc. (Keeler) Flashcards
The “39 week” rule
“Elective” delivery (IOL) or scheduled C/S is (WAS) notorious for inadvertent “premies” and NICU admissions………………SO
Have “reliable dates”
In normal case, NO elective delivery before 39 weeks. Otherwise, YOU get to appear in front of The Committee.
Dystocia
“DYSTOCIA” = DIFFICULT LABOR
30-50% Maternal Deaths world-wide
Fistulae, anemia, infertility
↑ fetal and neonatal risks
Simple & Safe = Cesarean Section “C/S”
Which “World” is patient in??????
Risk factors for Dystocia
Younger (esp 12 y/o) - & older (>35) Short, obese LGA = macrosomia (EFW=????) Pelvic deformity/contracture/trauma hx Hx prior C/S or prior dystocia Multiple gestation / malpresentation “Grand multipara”
When to induce = IOL
Risk of continuing > benefit Post dates (?40+, ?41+, never >42) (remember we need a “reliable” EDC?) ROM 12-24 hrs and > 34 weeks PIH Maternal DM and GDM IUGR Cholestasis of Pg No data: - Multiples - Macrosomia - Prior Precip delivery - Unstable lie
How to induce labor
DON’T = DO NOT STRIP MEMBRANES
It hurts, it’s risky, it doesn’t work
AROM, oxytocin, cervical “ripening”
Bishop score (of cervix) helps decide
“Urgency” helps decide
CAUTION IF PRIOR C/S
OXYTOCIN (=“Pitocin®”) Infusion
Standard dilution – from Pharmacy Infusion pump Rate is in mU/min * Start @ 0.5-2 * Increase by 1-2 mU/min every 30 mins * Max = 20, then reassess * STANDARDIZED PROTOCOL
FUN FACTS re: oxytocin
Misuse of oxytocin = big source of liability
Protocol is a SAFE HARBOR/shelter
DO IT THE SAME WAY EVERY TIME
Since protocol introduced, HCA has had more liability from FALLS IN THE PARKING LOT than from “Bad Babies”
Diagnosis and TX of DYSTOCIA
It IS all about the P’s
POWERS – ARE THE UC’S ADEQUATE?
PASSENGER (+ PRESENTATION + POSITION)
PASSAGE – true obstruction?
PSYCHOLOGY – PAIN RELIEF?
Macrosomia/Shoulder Dystocia
EFW = not accurate
A lot of cases of shoulder dystocia = normal size baby!
Fetal anterior shoulder stuck behind SP?
Prevention? Maybe – with ALL deliveries, mind that shoulder – use your index finger to gently rotate it “towards the baby’s nose”
Prevention – liberal use of C/S
Shoulder dystocia Do’s and Don’ts
Do NOT “pull” on head. “Support it only, keeping neck straight.”
Get HELP
Be CALM (yup, you MUST)
“McRoberts” position of mother
Maneuvers – main focus is on the “oblique”
Cesarean – Historical points
NO NO NO – Julius Caesar was not born this way – his mother was alive after his birth….. 95++% maternal mortality until: Proper closure – of UTERUS c.1900 Antibiotics c.1930’s Blood transfusions c.1940’s-1950’s Excellent anesthesia c.1980
Cesarean - Indications
Dystocia Fetal status = “non-reassuring” Breech/other malpresentation Hemorrhage Prior C/S
TYPES OF CESAREAN
LTCS = Low Transverse C/S
LTCS = MOST COMMON
Low Vertical - prematurity
Classical – placenta previa
Another type = “extraperitoneal” –in cases of infection (RARELY used)
Another type = “peri-mortem” = classical incision w/o closure – typically done in ER
“J” incision – if LTCS is extended up on one side
“ELECTIVE PRIMARY” C/S
CDMR = cesarean delivery on maternal request
ACOG President’s inaugural editorial in early 2000’s
Not “wrong” for pt to decide on this, but it IS wrong for (YOU) to proceed w/o informed consent!!!!!!!
LOS may actually be about the same
Cost may actually be about the same
Higher rate of NICU admissions are from days before we had the “39 week rule”
If your patient wants this, advise a separate “consent appointment” and be sure FOC is present!
VBAC/TOLAC
LOTS of conflicting data VBAC or C/S = both have risk Risk of VBAC ↑ with # of prior C/S: 1 = “OK” 2 = borderline 3 = call YOUR lawyer first
VBAC = Vag Birth After Cesarean TOLAC = Trial of Labor After Cesarean
statistics/ findings
Maternal Risk of death
- 2.8 per 10,000 with trial of scar
- 2.4 per 10,000 for elective CS
No maternal death ever attributed to scar rupture
Scar rupture
- Much confusion in the literature over the definition
- Rate of asymptomatic scar rupture the same whether VBAC or elect CS
- Overall rate approx. 0.5% or 1:200
- Was 0.35% in the largest combined contemporary study
Hysterectomy
- Additional risk from trial of scar is 3.4 per 10,000
- Requires 2941 elective CS to prevent one hysterectomy
A pregnant woman with acute chest pain
should have an immediate CT angiogram
Pulmonary embolism
Include in the above: Postpartum x 6 weeks
A patient with preeclampsia and shortness of breath
should have a chest X-ray immediately
Pulmonary edema
(Did YOU think of a Central Line?)
A hospitalized patient with preeclampsia and a systolic blood pressure of 160 or a diastolic pressure of 110
should receive an IV antihypertensive within 15 minutes
BP can rise rapidly → STROKE
acute, massive postpartum hemorrhage- what do we NOT do
Angiographic embolization should not be used
Bleeding is too fast!!
DO NOT GET BEHIND WITH PPH!
Any woman with cardiac disease
gets a maternal–fetal medicine consult
Pregnancy has 50% ↑ in maternal blood vol.
Strain on abnormal heart
CHF, etc
Do the MFM consult @ 8 weeks, not 38
If more than one dose of medication is needed to treat uterine atony,
go to the patient’s bedside until the atony has resolved
BE THERE FOR YOUR PATIENT
PPH = more rapid than you can possibly believe
Never treat “postpartum hemorrhage” without simultaneously
pursuing an actual clinical diagnosis
There is a DIFFERENTIAL DIAGNOSIS
May be TWO (or more) at one time
A postpartum patient who is bleeding or who recently has stopped bleeding and is oliguric
should not receive diuretics
Oliguria is due to HYPOVOLEMIA
YOUR diuretic will make it worse!!
Any woman with placenta previa and even one previous Cesarean
should be delivered in a tertiary care hospital
Abnormal implantation of placenta!
200 Units of blood!
Do YOU want to be the surgeon?
Every labor and delivery unit should have a
recently updated massive transfusion protocol
Our trauma colleagues are a vast reservoir of experience with massive blood loss
Be sure YOUR L&D unit has the protocol for your hospital!
