Threats to fetal oxygenation during labor– what is the context of your epidural? Tom Archer, MD, MBA January 31, 2012.

Slides:



Advertisements
Similar presentations
Tutorial June 25 Bio 155. Blood Cellular component: 1)RBC 2)WBC 3)Platelet.
Advertisements

Fetal Membranes 2 Dr Rania Gabr.
Fetal Development RC 290.
Prepared by: Mrs. Mahdia Samaha Alkony
Fetal Monitoring RC 290 Estriol By-product of estrogen found in maternal urine –Production requires functional placenta and fetal adrenal cortex Levels.
Anesthesia For Nonobstetric Surgery During Pregnancy May 6, 2005 R1 林群博.
Fetal Monitoring Review Questions Ana Corona 2009.
The course and conduct of normal labor and delivery
Carissa Santos Nilani Singler The Placenta Description of the Placenta The placenta is a multipurpose organ! It is involved in nutrient absorption, waste.
Placenta Dr. Lubna Nazli.
Intrapartum Fetal Surveillance.
CARDIOVASCULAR SYSTEM
Obstetric Hemorrhage Anne McConville, MD
Placental Abruption Liu Wei Department of Ob & Gy Ren Ji hospital.
ABNORMALITIES OF THE UMBILICAL CORD ASSOCIATE PROFESSOR IOLNDA ELENA BLIDARU MD, PhD.
Associate Professor Iolanda Elena Blidaru Md, PhD.
Placenta Quiz.
Dr. Madhavi Karki. CHORIONIC VILLUS SAMPLING AMNIOCENTESIS TIME10-12 WEEKS15-20 WEEKS RESULTBy direct preparation-24 hours, Culture.
Abnormal Umbilical Cord 、 Puerperium Women ’ s Hospital School of Medicine Zhejiang University Wang Zhengping.
بسم الله الرحمن الرحيم.
Placenta Dr. Lubna Nazli.
Fetal Monitoring Ultrasonography Monitoring: Chorionic sac during embryonic period placental and fetal size multiple births abnormal presentations biparietal.
Pregnancy and Embryonic Development. Fertilization Oocyte is viable for 12 to 24 hours after it is cast out of the ovary Sperm generally retain their.
With one woman dying during pregnancy or complications of childbirth every minute of every day, and 3.6 million neonatal deaths per year, maternal and.
Hypotension and respiratory failure after epidural test dose in a patient from the Birth Center. Tom Archer, MD, MBA Clinical Professor and Director, Obstetric.
Dr Ahmed abdulwahab. Hemorrhage is still one of the leading cause of maternal mortality all over the world DEFINITION Primary post partum hemorrhage.
The Circulatory System. The human circulatory system consists of the heart, a series of blood vessels, and the blood that flows through them.
Puntland Medical Association PMA نقابة أطباء بونتلاند HQ: Garowe tell:
Anesthesia for Cesarean Section -Emergent C/S & General Anesthesia Department of Anesthesiology,NTUH R3 Chang-Fu Su.
UNIT B: Human Body Systems Chapter 8: Human Organization Chapter 9: Digestive System Chapter 10: Circulatory System and Lymphatic System: Section 10.5.
Fetal Monitoring Introduction 1600’s Kilian proposes the use of fetal heart rate to diagnose fetal distress 1893 criteria for determining fetal distress.
INTRAPARTUM ASSESSMENT
Dr. Saeed Vohra.
المحاضرة الثالثة. The placenta is a discoid, organ which connects the fetus with the uterine wall of the mother. It is a site of nutrient and gas exchange.
Breech presentation occurs in about 2 to 4 % of singelton deliveries at term and more frequently in the early third and second trimester.
Uterine blood flow and tocolysis Tom Archer, MD, MBA UCSD Anesthesia.
Delivery in the ER Preparedness for Antepartum, Intrapartum, and Postpartum Complications Joel Henry, M.D. Associate Professor, Ob/Gyn.
Management of intrapartum fetal heart rate tracings.
Placenta previa Placental abruption
POST TERM PREGNANCY & IOL Dr. Salwa Neyazi Assistant professor and consultant OBGYN KSU Pediatric and adolescent gynecologist.
Hemodynamics, Thromboembolism and Shock Review with Animations Nicole L. Draper, MD.
Fetal Circulation Mike Clark, M.D.. Figure (a) Day 20: Endothelial tubes begin to fuse. (b) Day 22: Heart starts pumping. (c) Day 24: Heart continues.
Chapter 18: Anatomy of the Blood Vessels
ASSOCIATE PROFESSOR IOLANDA BLIDARU MD, PhD.
Fetal distress Women Hospital, School of Medical, ZheJiang University Yang Xiao Fu Abnormal Liquor Volume.
1 Clinical aspects of Maternal and Child nursing NUR 363 Lecture 4 Intrapartum complications.
Fetal Assessment During Labor
1 Elsevier items and derived items © 2010 by Saunders, an imprint of Elsevier Inc. Chapter 3 Antenatal Assessment and High-Risk Delivery.
Fetal Circulation.
1 Clinical aspects of Maternal and Child nursing Intrapartum complications.
Placenta &Amniotic fluid Dr. Dina Nawfal Dr. Dina Nawfal.
CHAPTER 14 Caring for the Woman Experiencing Complications During Labor and Birth.
Conception and Development of the Embryo and Fetus
Fetal Distress in labor Dr.Maysara Mohamed. What is fetal distress? Fetal distress is the term commonly used to describe fetal hypoxia. Hypoxia may result.
Abnormal Umbilical Cord Liquor Volume Abnormality Premature Delivery Premature Rupture of Membrane Prolonged Pregnancy, Multiple Pregnancy Women Hospital,
 Membranes are ruptured during a vaginal exam › With a crochet-like long hook › With a “finger-cot”  Head needs to be well engaged › Prevents cord prolapse.
Chapter 18 Fetal Assessment During Labor
Intrapartum Fetal Surveillance UNC School of Medicine Obstetrics and Gynecology Clerkship Case Based Seminar Series.
Chapter 17 – Intrapartum Fetal Surveillance
THE PLACENTA SHANNON MARKS, JENNA MILLER & JACLYN MILLER.
Agenda February 25th Today we will be….. Learning goals…..
Chapter 18: Anatomy of the Blood Vessels
Tom Archer, MD, MBA Clinical Professor and
Tom Archer, MD, MBA January 31, 2012
Abnormal Umbilical Cord、 Puerperium
Development After Implantation
Fetal Distress Dr. Mahboubeh Valiani Academic Member of IUMS
Presentation transcript:

Threats to fetal oxygenation during labor– what is the context of your epidural? Tom Archer, MD, MBA January 31, 2012

The fetus floats at the far end of a tunnel of oxygen delivery. If the tunnel is blocked, the fetus dies.

Systematic approach to thinking about the “risk context” of an epidural We can do the “usual things” directly related to hypotension more intelligently (fluids, pressors, LUD, O2. Think about “less usual things” (hyperstimulation, nuchal cord, pre-existing disease that make patient more precarious. Epidural may only be tangentially “to blame”– or not at all!

med.yale.edu manBody/SpiralsHumanBody.html The fetal oxygen supply is precarious– both on the fetal and maternal sides of the placental interface

Fetal-side (umbilical cord) problems with fetal oxygen supply

Nuchal umbilical cord

Knotted umbilical cord

Vasa previa– fetal blood vessels between presenting part and cervix– will rupture as presenting part descends.

Prolapsed umbilical cord

Maternal-side threats to fetal oxygen supply

Minimal collateral venous return to heart via lumbar and azygos system Open IVC Uncompressed aorta and iliac arteries Figure 1 Healthy, abundant uteroplacental perfusion Upper body Fetal O2 supply

Minimal collateral venous return to heart via lumbar and azygos system Open IVC Uncompressed aorta and iliac arteries Figure 2 Uterine contractions periodically deprive placenta of perfusion. Upper body Uterine contractions Fetal O2 supply

Increased collateral venous return to heart via lumbar and azygos system Compressed IVC Compressed aorta and iliac arteries ACC Figure 3 Aortocaval compression reduces placental perfusion pressure. Upper body Uterine contractions Fetal O2 supply Uterine mass

Manbit images

Ballas, Mantell, Archer SOAP 2012

Michard Both positive pressure ventilation and uterine contractions in the presence of free venous return cause the heart to receive periodic increases in venous return. Could these periodic volume challenges shed light on the parturient’s “volume status?”

Increased collateral venous return to heart via lumbar and azygos system Compressed IVC Compressed aorta and iliac arteries ACC Figure 4 Placental vascular disease (e.g. preeclampsia) further reduces placental perfusion. Upper body Uterine contractions Uterine mass Fetal O2 supply Placental vascular disease

Say “OUCH!” Pre-E mediators Poor placentation Pre-eclampsia: ischemic chorionic villi release pre-E mediators into maternal blood.

Poor-placentation theory of pre-E: Synciotrophoblast invades myometrium but does not denervate spiral arteries of mother properly. Hence, intervillous flow is sub- optimal. Chorionic villi are ischemic and release mediators (VEGF, etc) which damage maternal endothelium.

Increased collateral venous return to heart via lumbar and azygos system Compressed IVC Compressed aorta and iliac arteries ACC Figure 5 Placental abruption reduces placental volume available for gas exchange Upper body Uterine contractions Uterine mass Fetal O2 supply Placental spiral artery disease Placental abruption or thrombosis

Placental abruption decreases placental area available for gas exchange.

Increased collateral venous return to heart via lumbar and azygos system Compressed IVC Compressed aorta and iliac arteries ACC Figure 6 Epidural may be “straw that breaks camel’s back” and causes “fetal distress”. Upper body Uterine contractions Uterine mass Fetal O2 supply Placental vascular disease Epidural reduces arterial blood pressure Placental abruption or thrombosis

“Routine” epidural.

Your next epidural Ask yourself, “What are the pre-existing threats to fetal oxygenation in my patient?” “What special precautions should I take to prevent fetal hypoxia in this patient?” Be attentive to hyperstimulation, preeclampsia, abruption, hypotension, etc.

The End