30 min

conference.cast.com

30 min

911 IN THE OBSTETRIC SUITE:

MANAGEMENT STRATEGIES

FOR OB EMERGENCIES

Cynthia A. Wong, M.D.

May 2012


Disclosures

Off-Label uses of drugs will be discussed


Objectives

Learner Objectives: After participating in this activity, the learner

will be able to:

• Identify procedures and system changes for improving

outcomes of obstetric hemorrhage;

• Explain procedures and rationale for intrauterine resuscitation;

• Identify systems for defining urgency of unscheduled cesarean

deliveries (decision to delivery interval); and

• Explain the rationale for various anesthesia care plans for

urgent deliveries.


• Obstetric hemorrhage

Outline

• Intrauterine resuscitation

• Cesarean Decision-to-Delivery Interval (DDI)


Obstetric Hemorrhage

• Obstetric hemorrhage

– Blood Bank sample

– Estimating blood loss

– Postpartum hemorrhage protocol


Postpartum Hemorrhage

• Definitions:

– Vaginal delivery: > 500 mL

– Cesarean delivery: > 1000 mL

• Incidence: 4 - 5%


PPH Trends

Knight M. BMC Pregnancy Childbirth 2009;9:55


Deaths in NC: 1995 - 1999

Berg CJ. Obstet Gynecol 2005;106:1228


Specimen to Blood Bank

• Transfusion rate 0.4%

• NNT = 250

• $$$$$


Specimen to Blood Bank

• Transfusion rate 0.4%

• NNT = 250

• $$$$$

• TAT for blood products ≈ 1.5 h

• Strategies:

– O neg blood (4 units)

– Identify high-risk patients

– Draw & Hold


Blood Bank Specimen Protocol

All laboring patients

Scheduled cesarean

Specimen

Draw & Hold

Non-elective cesarean Type & Screen

High risk Type & Screen/Cross


Computerized Order Entry


Rhogam Therapy

• 57% had positive antibody screen

• Blood bank identification of antibody:

– 384 vs. 72 min

Cambic CR. Can J Anesth 2010;57:811


Postpartum Hemorrhage

• Frequent late recognition of hemorrhage

– Baseline hypervolemia

• Young, healthy patients

– Hidden blood loss

– Poor ability to estimate blood


Pretest: -38%

(95% CI -59 to -20%)

Posttest: -4%*

(95% CI -7 to -12%)

*P < 0.001

Toledo P. Am J Obstet

Gynecol 2010; 202:

400.e1-5


Estimating Blood Loss

Blood absorption characteristics of a

Standard laparotomy sponges (18in X 18in)

25 ml 50 ml 75 ml 100 ml

50% sat.

75% sat.

100% sat. no

dripping

100% sat.

dripping

Dildy. Visual Estimation of Blood Loss. Obstet Gynecol 2004.


• 1 cup = 250ml

Estimating Blood Loss

Familiar Objects

= 5 cm clot (orange)

= 1 unit PRBCs

• 12 oz soda can = 355 ml

• 2 cups = ~ 500 ml

=10 cm clot (softball)

= 2 unit PRBCs

Floor Spills

• 23 inches (50 cm) : 500 ml

• 34 inches (75 cm) : 1000 ml

• 45 inches (100 cm) : 1500 ml

Remember 1 gm = 1 ml


Toledo P. Sim Healthcare 2012;7:18


No observable abnormal bleeding, but maternal pulse rate >115bpm or

systolic pressure < 95mmHg may indicate postpartum hemorrhage

Press “OB Assessment” wall button and text alert “VS Changes”

Discuss need to enact postpartum hemorrhage protocol

Need for Type & Screen

Need for additional uterotonics

Need to move patient to L & D

If PPH protocol not enacted, document reason

Notify attending physician


Team Notification


http://whqlibdoc.who.int/pub

lications/2009/97892415985 #23


http://www.cmqcc.org/ob_hemorrha

ge/ob_hemorrhage_compendium_of

_best_practices


e) Cryoprecipitate – one dose


Cell Salvage

Sullivan I. Br J Anaesth 2008;101:225


Maternal Prewash Postwash Postfiltration

K+ (mEq/L) 3.8 3.8 1.5* 1.4*

Lamellar body

(K/mul)

Squamous

(/HPF)

Bacteria

(CFU/mL)

31.0 22.0 3.0* 0.0*

0.0 8.3 4.4 0.0

0.0 3.0 1.3 0.1

Fetal Hgb (%) 0.5 1.1 1.7 1.9

Waters JH. Anesthesiology 2000;92:1531 N = 14


Obstetric Hemorrhage

• Obstetric hemorrhage

– Protocol for Blood Bank sample

• Training for estimating blood loss

• Protocol for response to postpartum

hemorrhage


• Obstetric hemorrhage

Outline

• Intrauterine resuscitation

• Cesarean Decision-to-Delivery Interval (DDI)


Macones GA. Obstet Gynecol 2008;112:661


Macones GA. Obstet Gynecol

2008;112:661


Uterine tachysystole

• > 5 contractions in 10 min

• Individual contraction > 2 min

• Normal duration contractions < 1 min apart

Macones GA. Obstet Gynecol

2008;112:661


Sentinel Report

• Retrospective report of 30 laboring

patients

• Intrathecal fentanyl 50 g

• 9/30 had FHR below 100 bpm for up to

10 min

• Uterine hyperactivity noted (external

monitors)

• 2 Emergency CD

Clarke VT. Anesthesiology 1994


Fetal Bradycardia-Incidence

• 2-30%

• Incidence varies with definition

– FHR (


Fetal Bradycardia: Hypothesis

Neuraxial analgesia

↓Circulating maternal epinephrine

Clark VT. Anesthesiology 1994


Shnider S. Am J Obstet Gynecol 1983


Fetal Bradycardia: Hypothesis

Neuraxial analgesia

↓Circulating maternal epinephrine

↓Tocolysis

↑Uterine tone (hypertonus)

↓Uteroplacental perfusion

Fetal hypoxemia

FETAL BRADYCARDIA

Clark VT. Anesthesiology 1994


•Double-blinded RCT

•N = 77

•Combined spinal-epidural (CSE) vs. epidural

•1° outcome: Uterine tone and fetal bradycardia


Fetal Bradycardia: CD Rate

Study N Systemic/no

analgesia

Emergency

cesarean

Albright GA. Reg Anesth 1997;22:400

CSE

1389 1.3% 1.4%


Intrauterine Resuscitation

• Check maternal blood pressure

• Change maternal position

• IV fluid bolus

• D/C exogenous oxytocin

• Maternal oxygen therapy

• Tocolytic administration


Improve Fetal Oxygen Delivery

• Factors that can be altered:

– Difference between maternal and fetal oxygen

oxygen tension

– Placental blood flow


Improve Fetal Oxygen Delivery

• Improve oxygen delivery by

– Increasing oxygen content of fetal blood

– Ameliorating umbilical cord compression


Terbutaline vs. NTG


Contractions

Normal

5-6 / 10 min

> 6 / 10 min


• RCT, N = 110

• Nonassuring FHR tracing

• Terbutaline 250 μg IV vs. NTG 400 μg IV

• Primary outcome: successful acute

intrapartum fetal resuscitation


Position FSpO 2

(%)

Supine, HOB 30° 37.5 ± 9.3

Left lateral 48.3 ±7.8

Right lateral 47.7 ± 9.4

P-value P-value

< 0.03

0.90


Intrauterine Resuscitation

• Check maternal blood pressure

• Change maternal position

• IV fluid bolus

• D/C exogenous oxytocin

• Maternal oxygen therapy

• Tocolytic administration


• Obstetric hemorrhage

Outline

• Intrauterine resuscitation

• Cesarean Decision-to-Delivery Interval (DDI)


“All hospitals offering labor and delivery

services should be equipped to perform

emergency cesarean delivery. The

required personnal, including nurses,

anesthesia personnel, neonatal

resuscitation team members, and

obstetric attendants should be in the

hospital or readily available….


…No data correlate the timing of

the intervention with outcome,

and there is little likelihood that

any will be obtained.


However, in general, the consensus has

been that hospitals should have the

capability of beginning a cesarean

delivery within 30 min of the decision to

operate.


Some indications for cesarean delivery

can be appropriately accommodated in

loinger than 30 min. Conversely,

examples of indications that may

mandate more expeditious delivery

include hemorrhage from placenta previa,

abruption placentae, prolapse of the

umbilical cord, and uterine rupture.”

Guidelines for Perinatal Care, 6 h ed. AAP and ACOG 2007


“The problem is how we

define emergency cesarean

delivery. There is no

consistent definition…It

may be like pornography-

difficult to define, but easy

to recognize.”

Schauberger CW. Obstet Gynecol 2006


Definitions

• DII = decision to incision interval

• DDI = decision to delivery interval


30-min Rule

• Is a DDI (or DII) of 30 min routinely

achievable?

• Is a DDI (or DII) < 30 min necessary to

improve outcome?

• Suggested grading systems


30-min Rule

• Is a DDI (or DII) of 30 min routinely

achievable?

• Is a DDI (or DII) < 30 min necessary to

improve outcome?

• Suggested grading systems

• Are there risks to rushing?


Schauberger,

1994

Chauhan,

1997

O’Regan,

2003

Nasrallah,

2004

DII Studies

Country N DII (min) < 30 min

R US 75 23 (6,96) 63%

R US 117 52%

R Malawi 15 20 (6,75) 69%

R US 111 20 (5, 57) 75%

Bloom, 2006 P US 2808 65%

Chauleur P France 68 46 ± 7


Dunphy,

1991

Spencer,

2001

Tuffnell,

2001

MacKenzie,

2002

DDI Studies

Country N DDI (min) < 30 min

R UK 104 34 39%

P Australia 252 42

P UK 721 66%

P UK 383 43 24 39%

Bruce, 2002 P UK 118 39%


Helmy,

2002

McCahon,

2003

DDI Studies (cont.)

Country N DDI (min) < 30 min

P UK 70 71%

R UK 137 82%

Tan, 2003 R Singapore 30 20 (10,40) 76%

Sayegh,

2004

Lurie,

2004

R France 100 40 (12, 245) 49%

R Israel 71 26 11 71%


Onah,

2005

Hillemans,

2005

Bloom,

2006

Holcroft,

2005

DDI Studies (cont.)

Country N DDI (min) < 30 min

P Nigeria 224 511 674

201 248

0%

R Germany 109 10 (5-19) 100%

P US 2808 65%

R US 34 23 15


DDI vs. Indication for CD

Indication for CD N DII < 30

min

Umbilical cord prolapse

Placental abruption

Placental previa/hemorrhage

Uterine rupture

170 98%

Non-reassuring fetal status 1647 62%

13 academic centers (MFMUN)

Bloom SL. Obstet Gynecol 2006


DDI vs. Type of Hospital

Spencer MK. Aust N Z J Obstet Gynecol 2001


Reasons for Delays

• Awaiting anesthesiologist

• Awaiting pediatrician

• Delay in obtaining consent

• OR personnel not available

• Delay in transporting patient to OR

• Multiple attempts at NA


30-min Rule:

Conclusions

• Is a DDI of 30 min routinely achievable?

NO


30-min Rule

• Is a DDI of 30 min routinely achievable?

• Is a DDI (or DII) < 30 min necessary to

improve outcome?

• Suggested grading systems

• Are there risks to rushing?


Intrapartum Asphyxia

• Multi-factorial

• Poorly understood

• Difficult to diagnosis


DDI (min)

25

20

15

10

5

0

DDI

N=60 N=40

In-house Home

Korhonen J. Acta Obstet Gynecol Scand 1994


Number Neonates

Neonatal Outcome: Death and HIE

4

3

2

1

0

In-house Home

Korhonen J. Acta Obstet Gynecol Scand 1994

*

*P < 0.05


Abruption and fetal bradycardia

DDI 20 vs. 30 min, OR for poor outcome:

0.44 (95% CI 0.22 – 0.86)

Kayani SI. Int J Obstet Gynaecol 2003


% of parturients

Umbilical artery pH

100

80

60

40

20

0

7.4

7.3

7.2

7.1

7.0

† = different from 30 min

Col 17: 93.1

Col 17: 47.7

DDI < 30 min

DDI > 30 min

Arrested

Descent


Non-reassuring

fetal status

Wong CA. 2004

Unpublished


DII and Neonatal Outcome

Bloom SL. Obstet Gynecol 2006


Neonatal Outcome*

DDI (min) N (%) Adjusted OR (95% CI)

< 15 87 (6.5) 1

16 – 30 139 (5.5) 0.9 (0.6 to 1.2)

31 - 45 106 (3.0) 1.0 (0.7 to 1.4)

46 - 60 71 (2.2) 1.1 (0.8 to 1.7)

61 - 75 35 (1.9) 1.1 (0.7 to 1.7)

> 75 116 (3.1) 1.7 (1.2 to 2.4)

*5-min Apgar < 7

Thomas J. BMJ 2004


30-min Rule

Conclusions

• Is a DDI (or DII) < 30 min necessary to

improve outcome?

YES, BUT ONLY FOR LIFE

THREATENING CASES, AND THEN 30

MIN IS TOO LONG


• 10 cm VAS

– 0 = elective

Grading Systems

– 10 = life-threatening

• Anesthetic technique

– GA

– Quick spinal

– Top-up existing epidural

Lucas DN. J Royal Soc Med 2000


Grading Systems

• Maximum time to delivery

– < 5 min

– < 20 min

– < 40 min

• 5-point VRS

– 1 = elective

– 5 = life-threatening

Lucas DN. J Royal Soc Med 2000


• Clinical definitions

Grading Systems

– 1: Immediate threat to life of mother or fetus

– 2: Severe fetal of maternal compromise, but not

immediately life threatening

– 3: Needing delivery but no compromise

– 4: Elective

Weighted kappa = 0.91, agreement = 90%

Lucas DN. J Royal Soc Med 2000


Reasons for a Grading Scale

• Communications

• QM

• Research

• Improved safety for mother and neonate


DDI Summary

30-min DII not achievable for all nonelective

Cesarean deliveries

• DDI < 30 min only improves neonatal

outcome for “Grade 1” cases

• DDI > 75 min may be associated with

adverse neonatal and maternal outcome


Outline

• Outcomes in obstetric hemorrhage

• Intrauterine resuscitation

• Cesarean Decision-to-Delivery Interval (DDI)

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