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Transcript
4/2/2019
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Cesarean Birth Complications
Carol Burke MSN, APRN/CNS, RNC‐OB, CEFM
April 8, 2019
Disclosures• No FDA “off label” pharmaceutical or medical devices will be discussed in today’s presentation.
• No commercial support was received for this presentation.
• No conflict of interest
Objectives
1. Review assessments and interventions for complications of hemorrhage, surgical site infection and venous thromboembolism following cesarean birth
2. Compare early warning systems to identify maternal deterioration.
3. Discuss use of evidence‐based bundles in management of cesarean birth complications.
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Barber et. al, 2011
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Why us rate at 32%?
• EFM• Without any evidence at all to suggest continuous fetal monitoring improves outcomes, it has become a standard of care. False positive outcome
•Macrosomia• There’s no simple test to determine a baby’s size
•Duration second stage• Varied opinion on how long a woman should spend pushing before a C‐section is called
•Defensive medicine• If a baby is born via C‐section and there’s a bad outcome, you can say everything was done
Sakala 2013
Definitions of Labor Progress per the ACOG/SMFM Consensus Statement
• Prolonged latent phase as currently defined is not indication for c/s
• Slow but progressive labor in the 1st stage should not be indication for c/s
• Cervical dilation of 6cm is a threshold for active labor and standards of active labor progress should not be applied before then
• C/S for active phase arrest in 1st stage should be reserved for women beyond 6cm with ROM who FTP despite 4 hours of adequate contractions or 6 hours of oxytocin administration.
20.2
28.5
36.3
47.9
0
10
20
30
40
50
< 20 20‐29 30‐39 40+
C/S rate by age
C/S rate
Cesarean delivery rate: Number of births delivered by cesarean per 100 births.
National Center for Health Statistics
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Cesarean Rates by State 2017
Is there a better way to calculate rate?
• 10 group classification system – Robson
• Allows standardized comparisons of data
• Identifies clinical scenarios driving changes in cesarean rates.
• Hospitals and health organizations can use the Robson 10‐Group Classification System to evaluate quality and processes associated with cesarean delivery.
• Throughout birthing process• Prolonged second stage• Prolonged oxytocin use• Active bleeding• Chorioamnionitis• Operative vaginal delivery• Cesarean birth (especially emergent/urgent)• Retained placenta
• Postpartum
• AWHONN recommends that cumulative blood loss be formally measured or quantified after every birth.
• Calibrated under‐buttocks drapes to measure blood loss
• Dry weight card, laminated and attached to all scales, for measurement of items that may become blood‐soaked when a woman is in labor or after giving birth
• With C/S ‐ Suction and measure all amniotic fluid within the suction canister of collected fluid before delivery of the placenta.
• Rapidly infuse crystalloids while blood products are being obtained
• Accurate vital signs
• Prevent hypothermia via use of external adjuncts for patient warming.
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Management plan (Continued)
• Use pulse ox
• Maintain oxygenation 8‐10L/min via nonrebreather mask
• Discuss with anesthesia or ICU team need for invasive hemodynamic monitoring especially with large volume replacement and ease of blood draws with central line
• The prothrombin time (PT), activated partial thromboplastin time (aPTT) and International Normalized Ratio (INR) tests were developed to assess and adjust dosing of anticoagulant medications such as warfarin (INR) and heparin (aPTT).
Fluid Replacement ‐ Crystalloids
• Lactated Ringer's is a mildly hypotonic solution often used for large‐volume fluid replacement.
• Sodium chloride at 0.9% concentration is close to the concentration in the blood (isotonic).
Crystalloid replacement 3:1 ratio 3 liters of crystalloid to each liter of blood loss
Platelets 50 Platelets, RBC, WBC, plasma Increase platelet count 5,000‐10,000/mm3 per unit
Fresh Frozen Plasma
250 Fibrinogen, antithrombin III, factors V and VIII
Increase fibrinogen by 10mg/dL
Cryoprecipitate 40 Fibrinogen, factors VIII and XIII, von Willebrand factor
Increase fibrinogen by 10mg/dL
Blood Component Therapy
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Communicate
Communicate
Communicate
•Make the mental shift from “normal delivery” to
• Clarify between the Obstetrician and Anesthesiologist regarding who will primarily manage blood loss quantification, laboratory assessment, and blood component therapy
• Be responsible to alert OB and Anes regarding• Blood volume loss
• Vital signs, I&O•Mental status
• Document as you go
Communicate
Communicate
Communicate
• Alert charge nurse, OR team, IR readiness, blood bank
• Insist that the MD evaluate at the bedside, not just on the phone
• Do a time‐out with every escalation of blood loss to the next tier ( acronym)
ackground / blood product availability
ab data / time drawn
BL total / increase in last hour (quantification)
mergency team notified
ecision / plan
Communicate
Communicate
Communicate
Don’t forget the family
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Surgical site infectionfollowing cesarean birth
Infection accounts for a disproportionate contribution to maternal mortality.
Incidence of SSI
• Cesarean birth is the single most important factor associated with
postpartum infection and carries a 5‐20 fold increased risk of infection
when compared to vaginal delivery
• Some studies show up to 20% of all women develop a postpartum
infection as:
• Endometritis (3X more common after C/S in Stage 2 vs. Stage 1)
• Wound infection and
• Urinary tract infection
• 85% occurring within 7 days of hospital discharge
Lamont et al., 2011Axelsson et al., 2018
SSI Definition / Category
Superficial incisional
Deep incisional
Organ / space
Infection which occurs within 30 days after operative procedure (Cesarean section) and must meet the
following criteria:
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Superficial incisional
Skin and subq tissue + 1 of the following:• Purulent drainage• Organisms from culture• Pain, tenderness, swelling, redness or heat• Diagnosis by a surgeon or attending MD
Deep incisional
Deep soft tissue (fascia and muscle) +1 of the following:• Purulent drainage• Spontaneous dehisces or opened by MD • Fever > 38C, localized pain or tenderness• Abscess found on exam or reoperation or radiologic
exam• Diagnosis by a surgeon or attending MD
Organ/space
Infection involves any part of the anatomy deeper than the fascial/muscle layers that is opened or manipulated during operative procedure +1 of the following:
• Purulent drainage from a drain into the organ• Culture of fluid/tissue• Abscess or evidence of infection involving the organ found
on exam or reoperation or radiologic exam• Diagnosis by a surgeon or attending MD
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Endometritis
• Infection of the lining of the uterus
• The most common cause of postpartum fever
• Endometritis complicates the postoperative course of a cesarean delivery 6‐27% of the time
• Signs / Symptoms
• Postoperative fever / chills
• Fundal / uterine tenderness
• Malodorous and/or purulent lochia
Haas, 2010
Evidence based bundle – surgical site infection
• Evidence based prophylaxis
• Anticipatory planningReadiness
• Risk factor assessment
• Identify etiology
• Recognize signs of sepsisRecognition
• Sepsis bundle
• Transfer to higher level of care
• Patient educationResponse
• Internal quality review
• M&M reviewReporting
Evidence‐based prophylaxis
• Preoperative washing for scheduled cesarean:
• Lowers the microbial load at the surgical site and risk of surgical site
contaminants
• Shower or bathe with antimicrobial soap night before C/S
• Consider vaginal cleansing
• Immediately prior to the cesarean birth, especially for women with
ruptured membranes and those who have labored prior to surgery.
• Currently, only povidone‐iodine is approved for use in the vagina, (swab
for 30 seconds) however, off‐label use of chlorhexidine solutions can be
considered, especially in women with allergies to iodine
• Utilize intraoperative skin preparation with chlorhexidine products or povidone
iodine products
AORN, 2018CDC Guideline for the Prevention of Surgical Site Infection,
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Prophylactic Antibiotics
• A narrow‐spectrum, first‐generation cephalosporin: cefazolin (Rx)
• Women with a penicillin allergy: A single dose combination of clindamycin with an aminoglycoside is a second option
• Timing: Ideally, the administration of prophylactic antibiotics should occur 60 minutes prior to skin incision, whenever possible.
• Administer additional doses of antibiotics or higher doses of antibiotics if indicated.
• Surgical procedures lasting longer than 3–4 hours• Obesity• Excess blood loss
• For GBS: (fetal benefit) determine the need for intrapartum prophylaxis in the case of unplanned cesarean or planned cesarean with rupture of membranes.
AAP & ACOG, 2017
Hypothermia prevention
•Hypothermia is associated with cardiac events, delayed surgical wound healing, surgical site infections, increased blood loss, increased hospital stay, and thermal discomfort.
•Suggested methods to maintain temperature:• Forced air• Warmed blankets
• Warmed IV fluid
• OR temperature at 20–23º C (68–73º F)
SSI RiskPatient related factors
Pregnancy related factors
Procedure related factors
● Obesity● Chronic hypertension● Tobacco use in pregnancy● Lower socioeconomic status● ASA class >= 3
● Gestational diabetes● Labor prior to cesarean or
emergent cesarean● ROM > 6 hours● Inadequate prenatal care
● > 6 vaginal exams during labor● Operative time > 49 minutes● Increased blood loss > 500 mL● General anesthesia● Type of closure
(staple vs. subcuticular)● Type of incision● Surgical drains
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When should I do AN infectionrisk assessment?
•Antepartum•On admission
• Throughout birthing process• Prolonged second stage• Prolonged oxytocin use• Active bleeding• Chorioamnionitis• Operative vaginal delivery• Cesarean birth (especially emergent/urgent)• Retained placenta
• Postpartum
4 pathways of invasion
Retrograde infection from the pelvis via the
fallopian tubes
MOST COMMON
Incision type
• Joel‐Cohen incision was found superior to Pfannenstiel for reduced morbidity in obese women
• Joel‐Cohen is a straight incision that is 3 cm below the line joining both anterior superior iliac spines.
• Normal physiological changes during pregnancy can cause abnormal readings when compared with the non‐pregnant population, potentially leading to a missed diagnosis of sepsis.
Hypotension
A systolic blood pressure of • <90 mm Hg, • mean arterial pressure <70 mm Hg,
or • reduction of >40 mm Hg from
baseline.
Symptoms of sepsis
• Trauma
• Retention due to loss of tone
• Cesarean birth
• Dehydration with prolonged labor
• Antidiuretic effect of oxytocin
Decreased urinary output
Urinary output may decrease also due to:
Symptoms of sepsis
• Exhaustion following labor
• Effect of narcotic administration
Changed mental state
Lethargy may also due to:
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• Lactic acid is a by‐product of anaerobic metabolism (serum lactate)
• Poorly perfused tissue beds result in global tissue hypoxia which result in increased serum lactate
• A serum lactate is correlated with increased severity of illness and poorer outcomes even if hypotension is not present
• May be elevated in labor…
Want a lactate drawn?
SYMPTOMS OF SEPSIS
The most important change in the revision of the Surviving Sepsis Campaign bundles is that
the 3-hour and 6-hour bundles have been combined into a single “Hour-1 Bundle”
with the explicit intention of beginning resuscitation and management immediately.
3 hour bundle
6 hour bundle
1 hour bundle
Evidence based bundle ‐ sepsis
1 hour bundle
effective 5/11/18
Measure Blood Lactate
• Remeasure if initial lactate is >2 mmol/L.• A high lactate level indicates that the tissues are not getting enough oxygen
Perform Blood Culture
Antibiotics
IV Fluids
Vasopressors
• Blood cultures identify the cause of the infection.• Should be taken before antibiotics are administered, if possible.
• Broad‐spectrum antibiotics that are active against the causative organism
• Rapid administration of 30ml/kg crystalloid for hypotension or lactate > 4mmol/L
• Raise blood pressure• This is a critical resuscitation step in patients with septic shock.
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Nursing implications
• Aware of potential maternal deterioration
• Vigilance with vital sign and symptom assessment
• Prompt administration of antibiotics
• Delivery is not always the ‘cure’ for the mother with
intraamniotic infection
• Patient education for signs of maternal infection
• Attend / participate in severe maternal morbidity review
sessions
Complication: Venous thromboembolism
The risk of VTE is 4 times greater after cesarean section compared to vaginal birth.
The risk of VTE is 4 times greater after cesarean section compared to vaginal birth.
80%
20%
VTE
DVTPE
Part of clot breaks off and carried to the lungs
(PE)
DVT causes pain and swelling
(rarely fatal)
Blood clot forms in deep vein
• chest pain• shortness of breath• hemoptysis (coughing blood) and, if large,
severe hypoxia and collapse, which can be fatal
• chest pain• shortness of breath• hemoptysis (coughing blood) and, if large,
severe hypoxia and collapse, which can be fatal
Venous thromboembolism
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VenousThromboembolism (VTE)
Deep Vein Thrombosis (DVT)
Pulmonary Embolism (PE)
1st trimester
2nd trimester3rd trimester
! 60 fold increase during first 3
months after birth
The incidence of VTE, is 2.6 per 1000 cesarean birthsThe incidence of VTE, is
2.6 per 1000 cesarean births
Stasis of blood flow
Endothelial injury Hypercoagulability
Virchow's triad
Hypercoagulability• Increased fibrinogen• Factor V Leiden mutation• Trauma• Late pregnancy and birth • Cigarette smoking• Obesity
Utilize the “3 bucket model” risk assessment that stratifies VTE risk in pregnant or postpartum women into three color-coded levels for rapid identification
Medium VTE RiskLow VTE Risk High VTE Risk
Hameed AB, Montgomery D, Peterson N, Morton CH, and A Friedman. Improving Health Care Response to Maternal Venous Thromboembolism. Developed under contract #11-10006 with the California Department of Public Health, Maternal, Child and Adolescent Health Division. Published by the California Department of Public Health, 2017.
Reduced mobility (bedrest with bathroom privileges for at least >72 hours
3
Thrombophilia 3
Acute infection and/or Rheumatologic disorder 1
Pregnancy 1
Obesity (BMI > 25 kg/m2) 1
Barbar, Noventa et al. 2010; D’Alton, Friedman et al. 2016; Harris, Sulmers et al. 2016
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symptoms of DVT
• Heaviness / swelling in affected limb• Warmth• Pain or tenderness• Redness, pallor or other change in skin color• Increased calf / thigh circumference
pulmonary embolus
Symptoms:
• Dyspnea / tachypnea
• Fever
• Tachycardia
• Hemoptysis
• Chest pain may be worse
with inspiration
Investigation:
• ABG• CT angiogram• Pulmonary angiogram
Mayo foundation for medical education and research