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Labor Emergencies

Labor Emergencies. Nate Hemmer, MD AGH EM Resident Sept 8, 2010. Objectives. Address emergent conditions of labor Epidemiology Pathophysiology Evaluation Diagnosis Management. Labor Emergencies. Fetal distress Prolapsed umbilical cord Preterm Labor Imminent delivery

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Labor Emergencies

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  1. Labor Emergencies Nate Hemmer, MD AGH EM Resident Sept 8, 2010

  2. Objectives • Address emergent conditions of labor • Epidemiology • Pathophysiology • Evaluation • Diagnosis • Management

  3. Labor Emergencies • Fetal distress • Prolapsed umbilical cord • Preterm Labor • Imminent delivery • Dystocia & Malpresentation • Hemorrhage • Severe preeclampsia & Eclampsia • Chorioamnionitis • Postpartum cardiomyopathy

  4. Epidemiology • 1/160-695 births occur in ED or prehospital setting • High rate of maternal & neonatal complication • Lack of sophisticated technology & experience • Little prenatal care • Frequently abuse of EtOH or drugs

  5. Evaluation • HPI: • Uterine Contractions • Vaginal fluid leakage • Vaginal blood loss • Fetal movements • Ob hx • PMHx / PSHx / Meds / Allergies • ROS: • Fevers, HA, Visual ∆, Sz, Wt ∆, Edema, Abd pain

  6. Evaluation • ABCs • Physical: • Vitals of mom and baby • Neuro • Abd • Vaginal exam (except in bleeding) • Fluid • Cervix: dilation / effacement / station • Edema

  7. Evaluation • Cardiac Monitor, O2, IV • Fetal Heart Monitoring (FHM) • Tocometry • Ultrasound • Labs: • CBC, T & S / C, BMP, LFTs, UA • Ob Labs: FFN, nitrazine, ferning

  8. FHM & Toco

  9. FHM • Good: • FHR 110 - 160 • Moderate variability • Accelerations (reassuring) • Absence of late or variables • Bad: • Flat • Late decels or severe variables • Prolonged deceleration • Brady- or tachycardia

  10. Differential: Absent variability • Cerebral hypoxemia • Acidosis • Anencephaly & CNS defects • Centrally acting drugs • Sepsis • Defective cardiac conduction • Quiet fetal sleep

  11. Late Decels • Due to maternofetal insufficiciency • Hypoxia and acidemia • Uterine rupture (especially with bradycardia) • Uterine abruption • Excessive uterine contractions • Maternal hypotension • Hypertensive disorders • Tx: • O2, position on side, IVF • Delivery

  12. Variables • Think umbilical cord compression • Nuchal cord • Cord prolapse • Oligohydramnios • Acidosis • Recurrent or severe is more concerning

  13. Uterine Cord Prolapse • Dx by exam (or ultrasound) • C/s delivery of choice • Delay increases mortality • Knee-chest position in Trendelenburg • Manually elevate presenting part • Stop pushing • Instilling 500 – 750 mL of saline into bladder • O2, IVF • If c/s not available: reduce cord and rapidly deliver

  14. Preterm Labor • Uterine ctx’s + cervical change before 37 wks • Presentations similar to term labor • Discuss & Transfer to Ob care • Tocolysis (avoid if delivery preferable): • Ca Channel Blockers: Nifedipine or nicardipine • NSAIDs: indomethacin (dangerous side effects) • β agonist : terbutaline • Magnesium

  15. Precipitous vaginal delivery • Delivery imminent if: • Complete effacement • Presenting part at introitus • ? tx to OB vs Ob coming to ED • Consider parity & stage of labor • Vaginal exam: presenting part

  16. Delivery : Preparation • Organized & collected approach • Vitals • Monitors • O2 • IV • Position patient : dorsal lithotomy (or knee-chest) • Prep and drape • Supplies • Backup

  17. Precipitous Labor: Supplies • Surgical scissors • Placenta basin • Rubber suction bulb • Neonatal airways • Hemostats • Cord clamps • Sterile gloves • Sterile towels and drapes • Gauze sponge (4 x 4)

  18. Delivery : Technique for OA • Gently stretch perineum • Support head & perineum • Suction • Check for Nuchal Cord • Deliver anterior shoulder • Deliver posterior shoulder • Clamp the cord • Clean, dry, & assess infant • Deliver placenta

  19. Labor Specific Drugs

  20. Dystocia • Diagnosed intrapartum • Inability to deliver either shoulder • Head retracts – “turtle sign” • Episiotomy • Drain the bladder

  21. Dystocia: Manuevers • McRobert’s manuever: • Knee-chest position • Suprapubic pressure • Rubin’s manuever: • Push accessible shoulder towards fetal chest • Wood’s corkscrew: • Rotate child by pushing shoulder & spine towards chest • Deliver posterior arm: • Sweep arm across chest and pull hand out

  22. Breech delivery • Avoid if at all possible • Frank & complete breech more favorable • If delivery imminent, diagnosis by palpation • Techniques to improve success: • Episiotomy • Mauriceau maneuver: • Flex fetal head using oral cavity (support fetal pelvis) • Do NOT: • Place traction on fetus • Hyperextend neck • Grasp fetus by waist • Allow arms to entrap

  23. Face, brow, and Compound Presentations • Dx by U/s, Leopold’s, or during vaginal exam • Face presentation are managed expectantly • Reference point is chin • Brow spontaneously convert to face or vertex in 50% • Compound presentation include extremity • Will proceed in premature or small fetuses • Labor arrest and cord prolapse are indications for c/s

  24. Twins, etc • Ideally, would like to know before delivery • Check presentation • Vertex / vertex can be delivered vaginally • Vertex / nonvertex can go either way • Nonvertex / nonvertex need c/s

  25. Uterine Inversion • Relatively rare (1 in 2000 deliveries) • Risk factors: excess traction, placenta accreta, Mg, 1° • Severe abd pain + absent uterus (that is bulging at Os) • Treat as soon as apparent: • Push fundus upward via introitus • Hold uterotonics (prevent cervical ring) • May need sedation & tocolytics • Once replaced, start Oxytocin & prostaglandin • Maintain uterine pressure until contraction

  26. Perimortem C-section • Initiate within 4 minutes of arrest • Must have viable infant • Uterus > umbilicus & (+) FHT • Midline vertical incision using large scalpel • Extend epigastrium to symphysis pubis • Carry through all layers to peritoneal cavity • Vertical incision in uterus from fundus to bladder • Incise placenta if present anteriorly • Deliver child, then clamp cord

  27. Hemorrhage • Most common complication of labor • Accounts for 25% of obstetric deaths • May be obscured by volume changes of pregnancy • Differential Diagnosis: • Uterine atony • Genital tract trauma • Retained placental tissue • Coagulopathy

  28. Uterine atony • Majority of PP hemorrhage cases (75-90%) • r/o Trauma and retained POC • Soft boggy uterus • Tx: • Uterine massage • Uterotonics: Oxytocin or Methyergonovine • T & C if unsuccessful

  29. Birth Trauma • 2nd most common cause of PP hemorrhage • Tears & lacs to any GU structure • May have large contained hematoma • Leads to shock without identifiable cause (firm uterus) • Leave tears for OB if you can

  30. Retained POC • 10% of PP Hemorrhage • Typically placenta separates as unit on cleavage plane • May have retained fragments from excessive traction • Tx: • Digital exploration with blunt dissection • Will free normal tissue

  31. Placenta Accreta, Increta, Percreta • Adherent placenta • Varying degrees of placental penetration • Tissue will not separate with blunt dissection • Needs operative removal

  32. PP Hemorrhage : Management • Retained POC : Placental removal • Risks: infection, perforation, worsening hemorrhage • Monitor, IV, T & C • Trace cord to placenta • Attempt digital dissection with palm facing placenta • If adherent -> placenta accreta / increta / percreta • Check for retained cotyledons

  33. PP Hemorrhage: Management • Uterine Packing • Now uncommon (ineffective, infection, perforation) • 15 – 20 yards of 4” gauze using ringed forceps • Goal of tamponade • Temporizing measure • Pelvic Vessel Embolization • Alternative to hysterectomy • Interventional radiology

  34. PP Hemorrhage: Management • Uterotonic Agents: • Oxytocin: 1st line • 10 units IM or 20 units IV • Ergot alkoloids: Methergonovine • Caution in Pre-eclampsia, HTN, or comorbidities • Prostaglandins • Hysterectomy • Needed for life-threatening bleeds • Early intervention limits DIC risk • Check DIC panel

  35. Uterine Rupture • Associated with prior uterine surgery (ie c/s) • Range from simple dehiscence to fetal expulsion • Prolonged decels most sensitive • Tx: • Immediate surgery / c-section (30 minute window) • Uterotonic agents contra-indicated

  36. Amniotic Fluid Embolism • Rare event (increased in multiparous) • IV amniotic fluid -> procoagulant or anaphylactic cascade • Dyspnea, hypoxia, AMS, Sz, HD collapse • DIC frequent complication • High mortality

  37. Preeclampsia • Pre-eclampsia = HTN + proteinuria • Severe: BP > 160/110 with abd ttp, visual ∆, or severe HA • Vasospastic disease • Spectrum of disease with variable end-organ damage • Kidney, liver, CNS, heme • Evaluation: Vitals, Neuro, Abdomen, Edema • ROS: Edema, visual change, HA, n / v • Workup: CBC, CMP, Coag, FHM, Mg, FSBS • Tx: D/w Ob--? Admit, Bedrest, delivery

  38. Eclampsia • Eclampsia = Pre-eclampsia + Seizures • Management (along with severe pre-eclampsia): • Exclude other causes of sz (BS, drugs, CNS disease) • Magnesium sulfate: 4g IV/ 20 minutes +1- 2 g / hr IV • Monitor reflexes & respirations • Ca Gluconate 1 g for reversal • Monitor UOP & labs • If Sz persistent, lower DBP < 105 • Avoid diuretics & hyperosmotic agents; limit IVF • Deliver

  39. Chorioamionitis • Infection of chorion and amion (duh!) • Signs / sx’s: • Fever • Tachycardia • Malodorous vaginal discharge • Increased WBC • Fetal tachycardia & decreased variability • Treatment for anaerobic & aerobic bacteria: • Ampicillin + gentamicin

  40. Postpartum Cardiomyopathy • Unclear mechanism of disease • Mortality: 18 – 56% • Onset typically days to weeks post-delivery • Sxs: Mild fatigue to pulmonary edema • May develop CHF and dysrhythmia • Tx: • Diuretics, vasodilators, O2 • ACE-I (unless during pregnancy) • Half return to normal in 6 months • Others with residual LV dysfunction and mortality

  41. Transfer • High risk of ED delivery • Transfer to appropriate OB & neonatal resources • COBRA forbids transfer of actively laboring patient • Need to consider stage & parity • Consider maternal & neonatal outcome • Consensus with accepting physicians

  42. References • Harwood-Nuss • Marx • Tintanelli • Uptodate

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