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) -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

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

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

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 2 nd stage Medio lateral epi

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

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

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

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

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

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

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

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

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.

Other Injuries Extra cranial Intra cranial Facial Fx Neurologic Intra abdominal

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

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

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

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

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

Frequency of birth trauma related to mode of delivery cases per 10,000 births Cesarean with laborCesarean no laborForceps assistedVacuum assistedSpontaneous birthTrauma Subdural or cerebral hemorrhage Intraventricular hemorrhage Subarachnoid hemorrhage Facial nerve injury Brachial plexus injury Convulsions CNS depression Feeding difficulty Mechanical ventilation Adapted from: data in Towner, D, Castro, MA, Eby-Wilkens, E, et al. N Engl J Med 1999; 341:1709.

2 nd stage 3hr NICU admission 4%8% Chorioamnionitis 3%12.5% Uterine atony 3.5%7.8%

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

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

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.