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In The Name Of God

In The Name Of God. Maternal & Fetal Safety in Labor & Delivery Laleh Eslamian MD. Associated Prof. Maternal Fetal Medicine, Shariati hospital, TUMS. Observational studies: Fecal incontinence in parous sisters> nulliparous sisters (2 – 3times)

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In The Name Of God

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  1. In The Name Of God

  2. Maternal & Fetal Safety in Labor & Delivery Laleh Eslamian MD. Associated Prof. Maternal Fetal Medicine, Shariati hospital, TUMS

  3. Observational studies: • Fecal incontinence in parous sisters> nulliparous sisters (2 – 3times) • Urinary incontinence in parous sisters> nulliparous sisters (4 times) • Among Pre menopausal women: SUI in parous > nulliparous. • Among Post menopausal women: Hx of pregnancy & child birth: little impact on SUI (Medications, age …) • Among Post menopausal women: Hx of at least 1 delivery: ↑ 2 times prolapse – C/R – RVO than nulliparas

  4. ASSOCIATION BETWEEN PFD & Pregnancy & Delivery 50% of incontinence, 75% of prolapse

  5. Pregnancy & child birth → pelvic floor injury Compression Stretching Tearing of nerves, muscles & connective tissue

  6. Pelvic floor injury in pregnancy &child birth are due to Neural injury: Anal sphincter injury: Medio lateral episiotomy Injury to the lavator axis & coccygeus muscles for occult injuries: Forceps delivery Prolonged 2nd stage Medio lateral epi

  7. Neural injury: • Descent of fetal head→ stretch & compression of pelvic floor & associated nerves • Risk factors for nerve damage: operative delivery prolonged 2nd stage ↑ BW • Most resolve after 1st year, some remain >5yr • Denervation injury may accumulate with ↑ parity.

  8. CAN OBTETRICAL CARE BE MODIFIED TO REDUCE PFD? 1- C/S before labor: no RCT weak evidence to support preventive role for C/S (2006 National Institution of Health). 7 should undergo C/S to permit 1 woman from developing PFD latter in life

  9. 2- Changes in labor management *avoidance of episiotomy (anal sphincter trauma) *avoidance of operative delivery (FI, pudendal neuropathy) other factors? CPD – race. *oxytocin use (no RCT) *epidural anesthesia (no RCT) *macrosomia: could influence → OB intervention PFD

  10. 3- Prophylactic pelvic floor muscle exercises: No effect (during pregnancy & post partum) 4- Limiting Parity: Risk of prolapse doubles after 1st birth ↑10% with each additional delivery 5- Other strategies: Age – race – smoking – obesity (non modifiable)

  11. Alternatives to operative vaginal deliveries (OVD) • C/S • Expectant management: delayed pushing maternal rest change in mat. position emotional support • Augmentation with oxytocin

  12. Selected Issues SUI during pregnancy: The best delivery plan? some observational studies: SUI are less after C/S Some do not show this benefit C/S→↓ SUI by 12% not affected by SUI during pregnancy Further studies are needed

  13. Women who have undergone surgical repair. The best delivery plan: no Consensus

  14. Women with a prior anal sphincter laceration secondary repair: Carefully counseled about pregnancy & delivery Recommendation of experts → planned C/S

  15. Birth injuries of fetus - neonate • Overall incidence: 2% NVD, 1.1% C/S • ↑ Risk: macrosomia (>4000g), Mat. obesity, Breech, OVD, Small mat. size & Mat. pelvic anomalies • Most common: Soft tissue injuries (bruising – petechiae, subcutaneous fat necrosis, lacerations) • Lacerations are the most common injury associated with C/S.

  16. Other Injuries Extra cranial Intra cranial Facial Fx Neurologic Intra abdominal

  17. *Extra cranial: Caputsuccedaneum, cephalohematoma: resolves spontaneously *Intracranial: Subgaleal hemorrhage → massive blood loss → not managed appropriately → shock & death (4/10.000 NVD vs 59/10.000 vaccum) ICH: 3.7, 16.2, 17/10.000 *Facial injuries: Nasal septal dislocation (3d) Ocular injuries: (mild, resolves)

  18. Fx: Clavicle, humerus, femur, skull: resolve spontaneously Immobilization (4w) Neurologic injuries: Brachial plexus & facial, phrenic & laryngeal nerves resolve spontaneously Spinal cord injuries: poor prognosis

  19. Intra abdominal injuries Rare, rupture & hemorrhage in to the liver, spleen & adrenal gland.

  20. Neonatal Complications due to OVD: Short term→ head compression. traction on fetal intracranial structures, face, scalp Most serious: ICH Bruises abrasions, lacerations, facial nerve palsy, cephalohematoma, retinal hemorrhage, subgaleal hemorrhage, skull fx. Most of these occurs in the course of a spontaneous vag. delivery. presentation: 10hr

  21. (Continued) Long term: ICH (subdural, subarachnoid, IV, intraparencyhmal & neuromuscular injury) Vacuum <34w Vacuum: ↑ neonatal cephalohematoma, ↑ retinal hemorrhage VS. forceps or spontaneous vag. delivery Developmental outcomes = equivalant for forceps & vaccum

  22. Frequency of birth trauma related to mode of delivery cases per 10,000 births Adapted from: data in Towner, D, Castro, MA, Eby-Wilkens, E, et al. N Engl J Med 1999; 341:1709.

  23. 2nd stage < 3hr2nd stage > 3hr NICU admission 4% 8% Chorioamnionitis 3% 12.5% Uterine atony 3.5% 7.8%

  24. Dystocia & augmentationControl Spontaneous delivery 59% 92% Heavily meconium stained fluid 13% 8% PPH 4.02% 2.5% BW >4000g 19% 14%

  25. Patient safety: Minimizing error & preventing harm Reason for errors: Human fallibility Medical complexity System deficiencies Defensive barriers

  26. Strategies to reduce errors: & subsequent adverse out comes 1- Team & individual training 2- Simulation & drills 3- Development of protocols, guidelines, checklists. 4- Use of informative technology 5- Education.

  27. Thank You

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