Low Risk Obstetrics Session 2 Birthing Suite

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Low Risk ObstetricsSession 2Birthing Suite
PuerperiumDr. Kristine Whitehead2015
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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

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Spontaneous vaginal delivery

• video

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Management of Labour

• Your main responsibility on this rotation
• Respect labour, do not fear labour
• Active management is practiced at TOH

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Definition of Labour

• Regular, Frequent Contractions
• PLUS
• Cervical Change
• (Dilatation and Effacement)

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Definition of Labour

• Must diagnose labour correctly
• Otherwise can not diagnose labour dystocia

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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

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• 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

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• Third Stage
• Delivery of placenta

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Normal Labour - Friedman

• Historical data were collected before the
  widespread use of epidural analgesia
• Second stage values must be modified to reflect
  this

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1969 ODriscoll

• Active management of labour
• To prevent primips from labouring gt24 hrs
• Objective to decrease C/S rate

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ODriscolls 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

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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

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• Labor seems to progress more slowly now than in
  the 1950s
• Mean duration active labor 4.6 hrs. in 1950-60s
• Mean duration active labor 8 hrs. in 1980-90s
• WHY?

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Whats different?

• Mean body mass higher (BMI)
• Increased fetal size
• Increased maternal age
• Obstetric management eg. Induction, oxytocin,
  epidural, continuous monitoring

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Normal Labour

• 90 women who have successful vaginal birth
  progress gt1cm/hr after 5cm cervical dilatation
• Peisner DB, Rosen MG Transition from latent to
  active labor. Obstet Gynecol 68448, 1986.

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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

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Labour Dystocia

• Definition
• gt4 hrs of lt0.5 cm/hr dilatation
• (lt 2 cm dilatation in 4 hrs.)
• or
• gt1 hr of no descent during active pushing

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Labour Dystocia - Diagnosis

• Most common reasons for non-elective c-section
  (LSCS)
• labour dystocia/failure to progress 30
• non-reassuring FHR tracing 22
• Malposition/malpresentation 12
• Breech 9

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Labour Dystocia - Diagnosis

• Therefore
• Must diagnose dystocia correctly to reduce number
  of inappropriate C/S
• WHAT CAN GO WRONG?

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Labour Dystocia - 3 Ps

• POWER - hypotonic contractions
• - uncoordinated contractions
• - weak maternal expulsive
• effort

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Labour Dystocia - 3 Ps

• PASSENGER fetal position
• fetal attitude
• fetal size
• fetal abnormalities
• (e.g. hydrocephalus)

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Labour Dystocia - 3 Ps

• PASSAGE bony pelvis
  soft tissue
• (full bladder/rectum)

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Labour Dystocia - 3 Ps

• 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

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Labour Dystocia - 3 Ps

• 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

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Labour Dystocia - 3 Ps

• 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)

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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

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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

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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

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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

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ARM

• Amniotomy for shortening spontaneous labour.
  Smyth RM, Markham C, Dowswell T. Cochrane
  Database Syst Rev. 2013 June6CD006167
• ? More FHR tracing abnormalities afterwards
• Intervention for dystocia, not for prevention

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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

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• Technique ( ? risk of cord prolapse)
• Avoid dislodging fetal head
• Fundal pressure/suprapubic pressure
• ARM during contraction
• Head is preferably engaged (station 0)

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Photos - amnihook

• practice

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Contraindications to ARM

• Unengaged presenting part - absolute
• Relative - Polyhydramnios
• Relative - Hepatitis B/C or HIV, GBS not on ABs

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Augmentation of labor

• Low dose vs. high dose protocol
• Risks and benefits must have informed consent
• Properties of pitocin

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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 (gt 40mU/min)
• Half-life appx 5 mins

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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

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Persistent dystocia

• True CPD (craniopelvic disproportion) management
  c-section
• Most CPD is relative so try other maneuvers first

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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

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Second Stage Management

• Generally, prolonged 2nd stage occurs at
• Primip 3 hr with epidural
• 2 hr without epidural
• Multip 2 hr with epidural
• 1 hr without

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Second Stage Management

• Ottawa Hospital uses In-House Clinical Practice
  Guidelines (CPGs), see myHospital
• Categorized
• Primip with and without regional anesthesia
• Multip with and without regional anesthesia

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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

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Active Management of the Third Stage

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

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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

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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

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Management of Labour - Case

• Phillipa 28 y.o. G1P0 EGA 395 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 -

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• 1 cm dil, 2 cm long, stn 2
• FHR 155 bpm, accels, no decels on IA
• Your assessment?
• What is your management?

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• 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 -

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• 4 cm dil., thin (1/4 cm), cephalic, intact
• FHR normal, 140-145 bpm, accels, no decels
• Your assessment?
• What now?

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• Uses shower/tub
• V/E 4 hrs later (0600)

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• Cx 5 cm, station -1
• FHR normal
• Assessment?
• Management?
• She has many questions about the epidural

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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

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• Epidural inserted 0700
• Now what?
• Do you need continuous EFM?
• When to reassess?
• Next exam -

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• 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?

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• Successful ARM for abundant clear liquor
• Over 30 mins. contractions increase to q2-3 mins.

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• V/E at 1100 hr Fully / station 0
• FH - occasional uncomplicated variable decels
• Uncomfortable with contractions, especially in
  her back
• What do you do?

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• Top-up the epidural
• Frequent postion change
• RN empties her bladder
• Re-assess in 1 hour as per protocol

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• 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?

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• 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?

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Fetal scalp electrode

• Technique see instructions with packaging
• Risks superficial scalp trauma, infxn
• Benefits accuracy, consistency of FHR
• Must have informed consent

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• V/E at 1300 (one hour later) spines 3
• Urge to push
• Plan?

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• Start pushing!!
• Call staff back

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• FH shows prolonged deceleration to 60 bpm x 3
  minutes at 1400
• Presenting part can be seen easily with pushing

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• 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?

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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

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• Break
• Practice simulation ARM, scalp electrode

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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

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A4/8E

• PP orders
• Vitals, care map assessment
• Breastfeeding on demand, rooming in
• LC, SW, DPH prn
• Vaccination (MMR, influenza), Rhogam prn
• Discharge planning

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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

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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?

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Postpartum EndometritisPresentation

• Fever /- chills
• Tenderness, pain - uterus
• Lochia may be foul, heavier bleeding

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Postpartum Endometritis

• Polymicrobial anaerobes and aerobes
• Potentially lethal esp GAS, clostridium
• Both cause toxic shock syndrome

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Postpartum EndometritisTreatment

• Clindamycin and Gentamicin iv
• Clindamycin po
• Doxycycline and Metronidazole
• Clavulin

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• Breastfeeding problem ie. Pain, weight loss,
  hungry baby
• Risk of dehydration, xs wt loss gt10
• ? Risk of pacifier
• ? Risk of formula
• ? Risk of PPD

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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?

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Management

• Support/encourage/teach
• LC consult
• Start hand expression, pumping

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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?

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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?

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• Assess supports
• SW consult
• PHD referral/HBHC request early visit

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QUESTIONS/COMMENTS