OBSTETRICAL EMERGENCIES: Postpartum Hemorrhage and Shoulder Dystocia
Camille Andy, MD ALSO Syllabus, 3rd ed January 31, 2003
Objectives
• Review risk factors and causes of PPH and Shoulder Dystocia • Review Management Strategies
– The 4 T’s – HELPERR
Postpartum Hemorrhage
• Definition: > 1000 ml blood loss w/in 24 hours after delivery (avg loss < 500ml) • 3 - 5 % of vaginal deliveries • Potentially serious complications for mother • Third leading cause of maternal deaths worldwide
Risk Factors
ANTEPARTUM
• • • • • • • • Preeclampsia Previous postpartum hemorrhage Multiple gestation Previous cesarean section Asian/Hispanic Multiparity Polyhydramnios Macrosomia
» Combs, Obstet Gynecol 77, 1991
RR
5.0 3.6 3.3 1.7 1.7 1.5
INTRAPARTUM
• • • • • • • • •
Risk Factors
RR
7.5 4.7 1.6 3.0 2.0 1.7 1.7
Prolonged third stage Left mediolateral episiotomy Midline episiotomy Arrest of descent Lacerations: vaginal, perineal Assisted delivery: forceps, vacuum Augmented labor Chorioamnionitis MgSO4 during labor
» Combs, Obstet Gynecol 77, 1991
Prevention
• • • • Treat anemia during prenatal care Avoid routine episiotomy Actively manage third stage Re-examine after delivery
Third Stage Management
Expectant
• Await separation • Leave cord uncut • Spontaneous placental delivery • Oxytocin / breast after placental delivery
Active
• Oxytocin with shoulder delivery • Cord clamped and cut early • Controlled cord traction
Active Management of Third Stage
• Cochrane Database shows significant decreases in PPH
– Moderate PPH (>500ml)
• OR=0.34, ARR=10%, NNT=10
– Severe PPH (>1000ml)
• OR= 0.40, ARR=1.5%, NNT=65
– Requiring Transfusion
• NNT=48
• No significant effects on baby or ability to deliver placenta
Resuscitative Measures
• • • • • • MAKE THE DIAGNOSIS! Call for help Airway, Breathing, Circulation Two large-bore IV’s Oxygen Stat labs: type & cross, hgb, coags, DIC panel • Consider transfusion
Treatment Approach for Postpartum Hemorrhage
• • • • Uterine massage Inspect for lacerations Medications Surgical intervention
CAUSES OF PPH: The Four T’s
• • • • TONE (70%) TRAUMA (20%) TISSUE (10%) THROMBIN (1%)
TONE - UTERINE ATONY
• Most common cause of PPH • Initial step = bimanual uterine massage and compression • Medications: Insufficient evidence that one is superior
– – – – Oxytocin Methylergonovine Prostaglandins Misoprostol, rectal
Oxytocin
• Drug of choice • Rhythmic contractions of upper uterine segment, placental separation • 10 - 40 Units in 1 liter at 250 cc/hr • IM (10 units) or IV infusion • No contraindications • Hypotension with IV push
Methylergonovine
• Methergine 0.2 mg IM only • contracts both upper and lower uterine segments tetanically • causes vasoconstriction and hypertension • contraindicated in hypertension/PIH • side effects: HTN, nausea, palpitations, HA • ?placental entrapment
PROSTAGLANDINS
• Hemabate, carboprost
– 15-methyl prostaglandin F2 alpha
• 0.25 mg IM or intramyometrial, q 15 min, maximum of 2mg • Rapid response 3-10 minutes, Effective 86% of time where other measures have failed
• Side effects: nausea, diarrhea, flushing, headache • Caution: asthma, HTN, cardio-pulmonary disease
Future Oxytocics
• • • • Carbotocin Misoprostol Gemeprost Prostadyl
Trauma
• • • • Uterine inversion Uterine rupture Vaginal or cervical lacerations Hematoma
Uterine Inversion
• Rare, but important to recognize quickly • Suspect if shock disproportionate to blood loss • Replace uterus immediately • Watch for vasovagal reflex
Uterine Inversion: Recognition
Uterine Inversion: Replace through Cervix
Uterine Inversion: Restitution
Uterine Rupture
• Associated with prior uterine surgery • Suspect if:
– – – – – sudden change in FHR tracing vaginal bleeding abdominal tenderness maternal tachycardia signs of shock are out of proportion to visible blood loss
CERVICAL LACERATION
VULVAR HEMATOMA
TISSUE
• Retained placenta
– Not delivered within 30 minutes – 3 % of deliveries
• Retained placental fragments • Invasive placenta
Abnormal Uteroplacental Implantation
Intraumbilical Oxytocin
• Reduces rate of manual removal and other consequences of retained placenta • 2 ml (20 IU) diluted into 20 ml NS • Injected into placental side of clamped cord
Manual Removal of the Placenta
• • • • • Cease uterine massage Identify cleavage plane Cup cotyledons in palm Explore uterine cavity Give oxytocin
Thrombin/Coagulopathy
• Pre-existing conditions
– ITP, von Willebrands
• Obstetric-related
– – – – Hypertensive disorders, HELLP Abruption Fetal demise Sepis
• Drugs (e.g. aspirin)
Coagulation Lab Studies
• • • • CBC with platelet count PT-INR, aPTT Fibrinogen level Fibrin split products / D-dimer
Treatment Guidelines
• Treat underlying disorder • Maintain:
– Fibrinogen > 100mg/dl with FFP – Platelets > 50,000 with packed platelets – Hematocrit > 30% with PRBCs
Postpartum Hemorrhage Summary
• Unpredictable - be prepared! • Uterine atony is the main cause • Remember 4-Ts:
– Tone, Trauma, Tissue, Thrombin
• Consider active management of third stage
Shoulder Dystocia
Background
• Impaction of the anterior shoulder against the symphysis after delivery of the fetal head • Incidence - varies by birthweight
– 0.3% in infants weighing 2500 - 4000 grams – 5-7% in infants weighing 4000 - 4500 grams
• > 50 % occur in normal weight infants
Risk Factors
• Prior shoulder dystocia • Gestational diabetes • Postdates pregnancy • Macrosomia • Maternal short stature • High prepregnany weight and weight gain • Abnormal pelvic anatomy • 1st stage protraction or arrest disorders • Prolonged 2nd stage • “Head bobbing” in 2nd stage • Instrumented vaginal delivery
Complications
Maternal
• soft-tissue injuries • anal sphincter damage • postpartum hemorrhage • uterine rupture • symphyseal separation • • • • •
Neonatal
brachial plexus palsy clavicle fracture humeral fracture fetal acidosis hypoxic brain injury
Prevention
• Elective cesarean delivery NOT indicated • Glycemic control • Weight control *Preconceptual and during pregnancy • Deliver in alternative positions or McRoberts • Deliver anterior shoulder with momentum of head
Recognition
• Fetal head retracts against perineum
– (“Turtle sign”)
• Gentle traction does not effect delivery • Proceed to HELPERR
HELPERR mnemonic
• • • • • • • H E L P E R R = = = = = = = Help (Call for additional assistance) Evaluate for episiotomy Legs (McRoberts Maneuver) Pressure (suprapubic) Enter the vagina Roll the patient (to hands and knees) Remove the posterior arm
H = HELP
• Activate institutional protocol
– Appropriate notification – Additional nursing staff – Additional back-up
• neonatal resuscitation personnel • obstetrical / surgical backup • anesthesia
E = Evaluate for Episiotomy
• Shoulder dystocia is not a soft-tissue dystocia • Consider when additional room needed for advanced maneuvers • Decision based on clinical judgment and response to initial maneuvers
L = LEGS
• McRoberts Maneuver
– Flex maternal hips so that thighs are on abdomen
• Effects
– Straightens the lumbosacral lordosis – Increases AP diameter of pelvis – Flexes the fetal spine
• Reduces > 40% of shoulder dystocias
P = PRESSURE
• Suprapubic pressure by assistant:
– CPR-style hand position – Force should act to adduct anterior shoulder – Initially continuous, but can involve a rocking motion – Attempt for 30-60 seconds
E = ENTER
• Rubin Maneuver
– Approach anterior fetal shoulder from behind – Exert pressure on scapula to adduct most accessible shoulder and rotate to oblique position – Continue McRoberts Maneuver
E = ENTER II
• Woods Screw Maneuver
– Approach posterior fetal shoulder from the front – Gently rotate shoulder toward symphysis – Combine with Rubin maneuver
• Birth attendant has one hand on each shoulder, rotating together
E = ENTER III
• Reverse Woods Screw Maneuver:
– Approach posterior shoulder from behind – Rotate fetus in opposite direction from Rubin or Woods Screw maneuvers – May be successful when previous maneuvers fail
R = Remove the Arm
• Follow posterior arm down to elbow
– usually anterior to fetal chest
• Flex arm at the elbow • Sweep forearm across fetal chest
– grasping hand directly and pulling outward may lead to fractures
R = ROLL the Patient
• Roll patient to “all-fours” position • Increases pelvic diameters • Movement and gravity may also contribute to dislodging the impaction • Deliver posterior shoulder with gentle downward traction
R = Roll the Patient
Maneuvers of Last Resort
• • • • • Deliberate clavicle fracture Zavanelli maneuver Muscle relaxation Abdominal surgery with hysterotomy Symphysiotomy
Zavanelli Maneuver
• Cephalic replacement followed by emergency cesarean delivery • Flex fetal head to replace • Requires anesthesia, OR team, tocolysis • Do not attempt if nuchal cord clamped and cut
Zavanelli Maneuver Abdominal Replacement
Abdominal Surgery with Hysterotomy
• Small case series reported (1998) • General anesthesia + cesarean incision • Abdominal surgeon rotates fetal shoulders from above, similar to Woods Screw • Vaginal delivery after abdominal disimpaction
Symphysiotomy
• • • • • • Used primarily in developing nations Local anesthetic injected over symphysis Skin incision down to symphysis Vaginal hand displaces urethra laterally Scalpel blade to cut ligaments Symphysis will then spread, allowing delivery
Summary
• Shoulder dystocia is common and lifethreatening emergency • Risk factors helpful, but difficult to predict • Anticipation and preparation are keys to successful management • Institutional protocol is recommended • HELPERR provides a structured approach to handling an emergent condition