Obstentrics_Williams

Obstentrics_Williams. VBAC rates are similar, and in some cases higher, among women with labor epidural analgesia compared with those using other forms of analgesia (Aviram, Following VBAC, some clinicians routinely document the integrity of a prior scar by placing a hand through the dilated cervix and along the inner surface of the lower uterine segment. But routine uterine exploration is considered by others to be unnecessary. In a longitudinal study of 3469 women who had a VBAC, seven uterine dehiscences and one uterine rupture yielded an overall event rate of 0.23 percent (Silberstein, 1998). They concluded that trans cervical evaluation need only be performed in symptomatic patients.


Obstentrics_Williams

Obstentrics_Williams. Currently, the benefits of routine scar evaluation in the asymptomatic woman are unclear, however, surgical correction of a dehiscence is necessary if significant bleeding is encountered. Our practice is to routinely examine these prior hysterotomy sites. Any decision for laparotomy and repair takes into consideration the extent of the tear, whether the peritoneal cavity has been entered, and the presence of active bleeding.


Obstentrics_Williams

Obstentrics_Williams. Progress of labor in women attempting TOLAC is similar to normal labor, and no speciic pattern presages uterine rupture (Graseck, 2012; Harper, 2012b; Sondgeroth, 2017). Before hypovolemic shock develops, symptoms and physical findings in women with uterine rupture may appear bizarre unless the possibility is kept in mind. For example, hemoperitoneum from a ruptured uterus may result in diaphragmatic irritation with pain referred to the chest. This may direct one to a diagnosis of pulmonary or amnionic fluid embolism instead of uterine rupture. As shown in Figure 31-5, the most common sign of uterine rupture is a nonreassuring fetl heart rate pattern with variable decelerations that may evolve into late decelerations and bradycardia. In 36 cases of such rupture during TOLAC, there were fetal signs of uterine rupture in 24, maternal signs in eight, and a combination of maternal and fetal in three (Holmgren, 2012). Few women experience cessation of contractions following uterine


Obstentrics_Williams

Obstentrics_Williams. were fetal signs of uterine rupture in 24, maternal signs in eight, and a combination of maternal and fetal in three (Holmgren, 2012). Few women experience cessation of contractions following uterine rupture, and the use of intrauterine pressure catheters does not assist reliably in the diagnosis (Rodriguez, 1989).


Obstentrics_Williams

Obstentrics_Williams. 2017; Shmudi, 2017). Perhaps related, almost a fourth of VBAC deliveries were completed with either forceps or vacuum (Inbar, 2017). he merican Academy of Pediatrics and the American College of Obstetricians and Gynecologists (2017) have concluded that epidural analgesia while pushing. The rupture apparently stimulated a reflex push, after which uterine tone may safely be used during TOLAC. diminished and fetal bradycardia worsened. FIGURE 31-6 Maternal-Fetal Medicine Units Network: rates of some complications with increasing number of repeat cesarean deliveries. (Data from Silver RM, Landon MB, Rouse OJ, et al: Maternal morbidity associated with mUltiple repeat cesarean deliveries. Obstet Gynecol 207:1o226, 2006.)


Obstentrics_Williams

Obstentrics_Williams. In some women, the clinical appearance of uterine rupture mirrors that of placental abruption. In most, however, there is remarkably little appreciable pain or tenderness. Also, because most women in labor are treated for discomfort with either narcotics or epidural analgesia, pain and tenderness may not be readily apparent. The condition usually becomes evident because of fetal distress and occasionally because of maternal hypovolemia from concealed hemorrhage. If the fetal presenting part has already entered the pelvis with labor, loss of station may be detected by pelvic examination. If the fetus is partly or totally extruded from the uterine rupture site, abdominal palpation or vaginal examination may be help ful to identiY the presenting part, which will have moved away from the pelvic inlet. A irm contracted uterus may at times be felt alongside the fetus. Sonography may be helpful.


Obstentrics_Williams

Obstentrics_Williams. With rupture and expulsion of the fetus into the peritoneal cavity, the chances for intact fetal survival are dismal, and reported mortality rates range from 50 to 75 percent. Fetal condition depends on the degree to which placental implantation remains intact, although this can change within minutes. With rupture, the only chance of fetal survival is aforded by immediate delivery-most often by laparotomy-otherwise, hypoxia is inevitable. If rupture is followed by total placental separation, then very few neurologically intact fetuses will be salvaged.


Obstentrics_Williams

Obstentrics_Williams. Thus, even in the best of circumstances, some etal outcomes wil be impaire. he Utah experiences are instructive here (Holmgren, 2012). Of the 35 laboring patients with uterine rupture, the decision-to-delivery time was < 18 minutes in 17, and none of these infants had an adverse neurological outcome. Of the 18 born > 18 minutes from decision time, the three infants with long-term neurological impairments were delivered at 31, 40, and 42 minutes. There were no deaths, thus severe neonatal neurological morbidity developed in 8 percent of this group of 35 women with uterine rupture. In a study using the Swedish Birth Registry, Kaczmarczyk and coworkers (2007) found that the risk of neonatal death following uterine rupture was 5 percent. In the Network study cited earlier, seven of the 114 uterine ruptures associated with TOAC-6 percent-were complicated by development of neonatal HIE (Spong, 2007).


Obstentrics_Williams

Obstentrics_Williams. Maternal deaths from uterine rupture are uncommon. Of 2.5 million women who gave birth in Canada between 1991 and 2001, there were 1898 cases of uterine rupture, and four of these-0.2 percent-resulted in maternal death (Wen, 2005). In other regions of the world, however, maternal mortality rates are much higher. From rural India, the maternal mortality rate associated with uterine rupture was 30 percent (Chatterjee, 2007).


Obstentrics_Williams

Obstentrics_Williams. With complete rupture during TOAC, hysterectomy may be required. In selected cases, however, suture repair with uterine preservation may be performed. Sheth (1968) described outcomes from a series of 66 women in whom repair of a uterine rupture was elected rather than hysterectomy. hirteen of the 41 mothers who did not have tubal sterilization had a total of 21 subsequent pregnancies. Uterine rupture recurred in four of these-approximately 20 percent. Usta and associates (2007) reported similar results. In another study, however, women with a uterine dehiscence were not more likely to have a subsequent uterine rupture (Baron, 2014).


Obstentrics_Williams

Obstentrics_Williams. Because of the aforementioned concerns with TOAC, most women in the United States undergo ERCD. his choice has several signiicant maternal complications, and rates of these rise in women who have multiple repeat operations. The incidences of some common complications for women with one prior transverse cesarean delivery who undergo an ERCD were shown in Table 31-2. Of note, half of cesarean hysterectomies done at Parkland Hospital are in women with one or more prior cesarean deliveries (Hernandez, 2013).


Obstentrics_Williams

Obstentrics_Williams. The Network addressed issues of increased morbidity in a cohort of30,132 women who had from one to six repeat cesarean deliveries (Silver, 2006). he rates of some of the more frequent or serious complications are depicted in Figure 31-6. In addition, rates of bowel or bladder injury, admission to an intensive care unit or need for ventilator therapy, and maternal mortality, as well as operative and hospitalization length, showed significantly rising trends. Similar results have been reported by others (Nisenblat, 2006; Usta, 2005). More diicult to quantiY are risks for bowel obstruction and pelvic pain from peritoneal �.� c0 4 ..A 2�): E0u First Second Third � Fifth (6201) (15,808) (6324) (347) Number of repeat cesarean deliveries (Number of women) TABLE 31-4. Some Recommendations of Professional Societies Concerning a Trial of Labor to Attempt VBAC CD cesarean delivery; VBAC vaginal birth after cesarean.


Obstentrics_Williams

Obstentrics_Williams. TABLE 31-4. Some Recommendations of Professional Societies Concerning a Trial of Labor to Attempt VBAC CD cesarean delivery; VBAC vaginal birth after cesarean. adhesive disease, both of which increase with each successive cesarean delivery (Andolf, 2010; Mankuta, 2013). Cook and colleagues (2013) from the United Kingdom Obstetric Surveillance System (UKOSS) described adverse sequelae of women with ive or more cesarean deliveries. These women had signiicantly higher rates of morbidity. Namely, the major hemorrhage rate increased 18-fold; visceral damage, 17 -fold; critical care admissions, IS-fold; and delivery <37 weeks, sixfold. Much of this morbidity was in the 18 percent who had a placenta previa or an accrete syndrome (Chap. 41, p. 773).


Obstentrics_Williams

Obstentrics_Williams. For providers and their patients, unfortunately, no large rndomized trials have compared outcomes of women with an intent to pursue either TOAC or ERCD. Most studies to date have compared actual routes of delivey rather than the intended route of delivery. hus, we agree with Scott (2011) regarding a "commonsense" approach. The woman-and her partner if she wishes-are encouraged to actively participate with her provider in informed consent. Counseling should include documentation of the prior uterine incision and discussion of risks, benefits, and success rates of TO AC or ERCD. This includes consideration of risks involving uture pregnancies. Ideally, counseling begins preconceptionally and continues throughout pregnancy, with lexible options extending up to delivery. For women who desire TOAC despite a factor that increases their speciic risk, additions to the consent form are recommended by the merican College of Obstetricians and Gynecologists (2017 a). Bonanno and colleagues (2011)


Obstentrics_Williams

Obstentrics_Williams. despite a factor that increases their speciic risk, additions to the consent form are recommended by the merican College of Obstetricians and Gynecologists (2017 a). Bonanno and colleagues (2011) have provided such an example. Brief synopses of professional society guidelines are shown in Table 31-4. Guidelines that tend to be more conservative are shown in Table 31-5.


Obstentrics_Williams

Obstentrics_Williams. TABLE 31 -5. Conservative Guidelines to Approach a Trial of Labor Following Cesarean Delivery Early during prenatal care Develop preliminary plan Revisit at least each trimester Be willing to alter decision Have facilities availability Review relative and absolute contraindications Reconsider risks as pregnancy progresses Tread carefully: > 1 prior transverse CD, unknown incision, twins, macrosomia Cautions for induction-unfavorable cervix, high station Consider AROM Respect oxytocin-know when to quit Beware of abnormal labor progress Respect EFM pattern abnormalities Know when to abandon a trial of labor ACOG American College of Obstetricians and Gynecologists; AROM = artificial rupture of membranes; American College of Obstetricians and Gynecologists (20l7a) Society of Obstetricians and Gynaecologists of Canada (2005) Royal College of Obstetricians and Gynaecologists (2007)


Obstentrics_Williams

Obstentrics_Williams. American College of Obstetricians and Gynecologists (20l7a) Society of Obstetricians and Gynaecologists of Canada (2005) Royal College of Obstetricians and Gynaecologists (2007) Offer to most women with one prior low-transverse incision; consider for t.IO prior low-transverse incisions Offer to wornen with one prior transverse lowsegment cesarean delivery; withs> 1 prior CD then VBAC likely successful but increased risks Discuss VB,\C option with women with prior low-segment cesarean delivery; decision between obstetrician and patient Safest with ability for immediate cesarean delivery; patients should be allowed to accept increased risk when not available Should deliver in hospital in which timely cesarean delivery is available; approximate timeframe of 30 minutes Suitable delivery suite with continuous care and monitoring; immediate cesarean delivery capability Not precluded: twins, macrosomia, prior lowvertical or unknown type of incision


Obstentrics_Williams

Obstentrics_Williams. Suitable delivery suite with continuous care and monitoring; immediate cesarean delivery capability Not precluded: twins, macrosomia, prior lowvertical or unknown type of incision Oxytocin or Foley catheter induction safe, but prostaglandins should not be used; macrosomia, diabetes, postterm pregnancy, twins are not contrai nd ications Caution with twins and macrosomia American Academy of Pediatrics, American College of Obstetricians and Gynecologists: Guidelines for Perinatal Care, 8th ed. Elk Grove Village, 2017 American College of Obstetricians and Gynecologists: Guidelines for vaginal delivery ater a previous cesarean birth. Committee Opinion No. 64, October 1988


Obstentrics_Williams

Obstentrics_Williams. American College of Obstetricians and Gynecologists: Guidelines for vaginal delivery ater a previous cesarean birth. Committee Opinion No. 64, October 1988 American College of Obstetricians and Gynecologists: Vaginal delivery after previous cesarean birth. Committee Opinion No. 143, October 1994 American College of Obstetricians and Gynecologists: Vaginal birth ater previous cesarean delivery. Practice Bulletin No.r2, October 1998 American College of Obstetricians and Gynecologists: Vaginal birth after previous cesarean delivery. Practice Bulletin No.r5, ] uly 1999 American College of Obstetricians and Gynecologists: External cephalic version. Practice Bulletin No. 161, February 2016


Obstentrics_Williams

Obstentrics_Williams. American College of Obstetricians and Gynecologists: Vaginal birth after cesarean delivery. Practice Bulletin No. 184, November 2017a merican College of Obstetricians and Gynecologists, Society for MaternalFetal Medicine: Nonmedically indicated early-term deliveries. Committee Opinion No. 561, April 2013, Reairmed 2017b Andolf E, Thorsell M, Kallen K: Cesarean delivery and risk for postoperative adhesions and intestinal obstruction: a nested case-control study of the Swedish Medical Birth Registry. Am] Obstet Gynecol 203:406.el, 2010 Aviram A, Hadar E, Gabbay-Benziv R, et al: Successful tolac in a population with a high success rate-what are the diferences? Abstract No. 923. Am ] Obstet GynecoIr216:S526, 2017 Babbar S, Chauhan S, Hammas I, et al: Failed trial of labor after cesarean delivery: indications for failure and peripartum complications. Abstract No. 818, Am] Obstet Gynecol208 (1 Suppl):S342, 2013


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Obstentrics_Williams. Barger MK, Dunn ]T, Bearman S, et al: A survey of access to trial of labor in California hospitals in 2012. BMC Pregnancy Childbirth 13:83,r2013 Baron], Weintraub AY, Eshkoli T, et al: he consequences of previous uterine scar dehiscence and cesarean delivery on subsequent births. Intr] Gynaecol Obstet 126(2):120,r2014 Baron], Weintraub A, Sergienko R, et al: Is vaginal delivery of a macrosomic infant after cesarean section really so dangerous? Abstract No. 799, Am ] Obstet Gynecolr208(1 Suppl):S335, 2013 Ben-Aroya Z, Hallak M, Segal 0, et al: Ripening of the uterine cervix in a post-cesarean parturient: prostaglandin E2 versus Foley catheter. ] Matern Fetal Neonatal Med 12(1):42r2002 Bennich G, Rudnicki M, Wilken-Jensen C, et al: Impact of adding a second layer to a single unlocked closure of a cesarean uterine incision: randomized controlled trial. Ultrasound Obstet GynecoIr47(4):417, 2016


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Obstentrics_Williams. Bonanno C, Clausing M, Berkowitz R: VBAC: a medicolegal perspective. Clin Perinatol 38:217, 2011 Bujold E, Blackwell SC, Gauthier R]: Cervical ripening with trans cervical Foley catheter and the risk of uterine rupture. Obstet Gynecol 103(1): 18 2004 Bujold E, Gauthier R]: Should we allow a trial oflabor after a previous cesarean for dystocia in the second stage of labor? Obstet Gynecol 98:652, 2001 Burgosr], Cobos P, Rodriguez L, et al: Is external cephalic version at term contraindicated in previous caesarean section? A prospective comparative cohort study. B]OG 121:230,r2014 Cahill A, Stamilio OM, Pare E, et al: Vaginal birth ater cesarean (VBAC) attempt in twin pregnancies: is it safe? Am] Obstet Gynecol 193: 1 050, 2005 Cahill AG, Odibo AO, Allswroth ]E, et al: Frequent epidural dosing as a marker for impending uterine rupture in patients who attempt vaginal birth after cesarean delivery. Amr] Obstet Gynecol 202:355.e1, 2010a


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Obstentrics_Williams. Cahill AG, Stamilio DM, Odibo A, et al: Is vaginal birth after cesarean (VBAC) or elective repeat cesarean safer in women with a prior vaginal delivery? Am ] Obstet Gynecol 195:1143,r2006 Cahill AG, Tuuli M, Odibo AO, et al: Vaginal birth ater caesarean for women with three or more prior caesareans: assessing safety and success. B]OG 117:422,r201Ob Cahill AG, Waterman BM, Stamilio DM, et al: Higher maximum doses of oxytocin are associated with an unacceptably high risk for uterine rupture in patients attempting vaginal birth after cesarean delivery. Am ] Obstet Gynecol 199:32.e1, 2008 Chatterjee SR, Bhaduri S: Clinical analysis of 40 cases of uterine rupture at Durgapur Subdivisional Hospital: an observational study. ] Indian Med Assoc 105:510,r2007 Chauhan SP, Magann EF, Wiggs CD, et al: Pregnancy after classic cesarean delivery. Obstet Gynecol 100:946, 2002


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Obstentrics_Williams. Chauhan SP, Magann EF, Wiggs CD, et al: Pregnancy after classic cesarean delivery. Obstet Gynecol 100:946, 2002 Cheng Y, Snowden], Cottrell E, et al: Trends in proportions of hospitals with VBAC: impact of ACOG guidelines. Am] Obstet Gynecol 21 0:S241, 2014 Chiossi G, Lai Y, Landon MB, et al: Timing of delivery and adverse outcomes in term singleton repeat cesarean deliveries. Obstet Gynecol 121 :561, 2013 Clark SL, Miller DO, Belfort A, et al: Neonatal and maternal outcomes associated with elective term delivery. Am ] Obstet Gynecol 200(2): 156. el,r2009 Coleman VH, Erickson K, Schulkinr], et al: Vaginal birth after cesarean delivery.r] Reprod Med 50:261, 2005 Cookr], ]avis S, Knight M, et al: Multiple repeat caesarean section in the UK: incidence and consequences to mother and child. A national, prospective, cohort study. B]OG 120(1):85, 2013 Cragin E: Conservatism in obstetrics. N Y Med] 104: 1, 1916


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Obstentrics_Williams. Cragin E: Conservatism in obstetrics. N Y Med] 104: 1, 1916 Dicle 0, Kiiciikler C, Pirnar T: Magnetic resonance imaging evaluation ofincision healing after cesarean sections. Eur Radiol 7:31, 1997 Durnwald CP, Rouse 0], Leveno K], et al: he Maternal-Fetal Medicine Units Cesarean Registry: safety and eicacy of a trial oflabor in preterm pregnancy after a prior cesarean delivery. Am] Obstet Gynecol 195: 1119, 2006 Eastman N]: Williams Obstetrics, 10th ed. Appleton-Century-Crofts, New York, 1950 Erez 0, Dulder 0, Novack L, et al: Trial of labor and vaginal birth after cesarean section in patients with uterine millerian anomalies: a population-based study. Am] Obstet Gynecol 196:537.e1, 2007 Ford M, Bateman BT, Simpson LL: Vaginal birth ater cesarean delivery in twin gestations: a large, nationwide sample of deliveries. Amr] Obstet Gynecol 195:1138,r2006


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Obstentrics_Williams. Ford M, Bateman BT, Simpson LL: Vaginal birth ater cesarean delivery in twin gestations: a large, nationwide sample of deliveries. Amr] Obstet Gynecol 195:1138,r2006 Fox NS, Gerber RS, Mourad M, et al: Pregnancy outcomes in patients with prior uterine rupture or dehiscence. Obstet GynecoIr123(4):785, 2014 Goetzl L, Shipp TO, Cohen A, et al: Oxytocin dose and the risk of uterine rupture in trial of labor ater cesarean. Obstet Gynecol 97:381, 2001 Graseck AS, Odibo AO, Tuuli M, et al: Normal first stage of labor in women undergoing trial oflabor after cesarean delivery. Obstet GynecoIr119(4):732, 2012 Gregory KD, Korst LM, Fridman M, et al: Vaginal birth ater cesarean: clinical risk factors associated with adverse outcome. Am] Obstet Gynecol 198:452. e1,r2008 Grinstead], Grobman W A: Induction of labor after one prior cesarean: predictors of vaginal delivery. Obstet Gynecol 103:534,r2004


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Obstentrics_Williams. Grinstead], Grobman W A: Induction of labor after one prior cesarean: predictors of vaginal delivery. Obstet Gynecol 103:534,r2004 Grobman W A, Gilbert S, Landon MB, et al: Outcomes of induction of labor after one prior cesarean. Obstet Gynecolr109:262, 2007a Grobman WA, Lai Y, Landon MB, et al: Can a prediction model for vaginal birth after cesarean also predict the probability of morbidity related to a trial oflabor? Am] Obstet Gynecol 200(1):56.e1, 2009 Grobman WA, Lai Y, Landon MB, et al: Development of a nomogram for prediction of vaginal birth ater cesarean delivery. Obstet Gynecol 109:806, 2007b Grobman WA, Lai Y, Landon MB, et al: Prediction of uterine rupture associated with attempted vaginal birth ater cesarean delivery. Am ] Obstet GynecoIr199:30.e1,r2008 Guise ]M, Denman MA, Emeis C, et al: Vaginal birth after cesarean: new insights on maternal and neonatal outcomes. Obstet Gynecol 115: 1267, 2010


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Obstentrics_Williams. Guise ]M, Denman MA, Emeis C, et al: Vaginal birth after cesarean: new insights on maternal and neonatal outcomes. Obstet Gynecol 115: 1267, 2010 Hamilton BE, Martin ]A, Osterman M], et al: Births: inal data for 2014. Nat! Vital Stat Rep 64(12):1, 2015 Hamilton BE, Martin ]A, Osterman M]: Births: preliminary data for 2015. Nat! Vital Stat Rep 65(3):1, 2016 Harper LM, Cahill AG, Boslaugh S, et al: Association of induction of labor and uterine rupture in women attempting vaginal birth after cesarean: a survival analysis. Am] Obstet Gynecol 206:51.e 1, 2012a Harper LM, Cahill AG, Roehl A, et al: he pattern oflabor preceding uterine rupture. Am] Obstet GynecoI207(3):210.e1, 2012b Harper LM, Cahill AG, Stamilio DM, et al: Efect of gestational age at the prior cesarean delivery on maternal morbidity in subsequent VBAC attempt. Am] Obstet GynecoI200(3):276.e1, 2009


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Obstentrics_Williams. Harper LM, Cahill AG, Stamilio DM, et al: Efect of gestational age at the prior cesarean delivery on maternal morbidity in subsequent VBAC attempt. Am] Obstet GynecoI200(3):276.e1, 2009 Hendler I, Bujold E: Efect of prior vaginal delivery or prior vaginal birth after cesarean delivery on obstetric outcomes in women undergoing trial of labor. Obstet Gynecol 104(2):2 3,r2004 Hernandez ]S, Wendel GO, Sheield ]S: Trends in emergency peripartum hysterectomy at a single institution: 1988-2009. Am] PerinatoI30:365, 2013 Hibbard ]U, Gilbert S, Landon MB, et al: Trial of labor or repeat cesarean delivery in women with morbid obesity and previous cesarean delivery. Obstet Gynecol 108: 125, 2006 Hochler H, Yafe H, Schwed P, et al: Safety of a trial of labor after cesarean delivery in grandmultiparous women. Obstet GynecoIr123:304, 2014


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Obstentrics_Williams. Hochler H, Yafe H, Schwed P, et al: Safety of a trial of labor after cesarean delivery in grandmultiparous women. Obstet GynecoIr123:304, 2014 Hofman MK, Sciscione A, Srinivasana M, et al: Uterine rupture in patients with a prior cesarean delivery: the impact of cervical ripening. Am ] PerinatoIr21(4):217,r2004 Holmgren C, Scott ]R, Porter TF, et al: Uterine rupture with attempted vaginal birth after cesarean delivery. Obstet Gynecol 119:725,r2012 Inbar R, Mazaaki S, Kalter A, et al: Trial oflabour after caesarean (TO LAC) is associated with increased risk for instrumental delivery. ] Obstet Gynaecol 37(1):44,r2017 Jastrow N, Chailet N, Roberge S, et al: Sonographic lower uterine segment thickness and risk of uterine scar defect: a systematic review. J Obstet Gynaecol Can 32(4):321, 2010a


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Obstentrics_Williams. Jastrow N, Chailet N, Roberge S, et al: Sonographic lower uterine segment thickness and risk of uterine scar defect: a systematic review. J Obstet Gynaecol Can 32(4):321, 2010a Jastrow N, Demers S, Chaillet N, et al: Lower uterine segment thickness to prevent uterine rupture and adverse perinatal outcomes: a multicenter prospective study. Am J Obstet Gynecol 215(5):604.e1, 2016 Jastrow N, Demers S, Gauthier Rl, et al: Adverse obstetric outcomes in women with previous cesarean for dystocia in second stage labor. Am J Perinatol 3,r2013 Jastrow N, Robere S, Gauthier RJ, et al: Efect of birth weight on adverse obstetric outcomes in vaginal birth after cesarean delivery. Obstet Gynecol 115(2):338,r2010b Jozwiak M, Van De Lest H, Burger NB, et al: Cervical ripening with Foley catheter for induction of labor after cesarean section: a cohort study. Acta Obstet Gynecol Scand 93:296, 2014


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Obstentrics_Williams. Juhasz G, Gyami C, Gyami P, et al: Efect of body mass index and excessive weight gain on success of vaginal birth after cesarean delivery. Obstet Gynecol lO6:741, 2005 Kaczmarczyk M, Span�n P, Terry P, et al: Risk factors for uterine rupture and neonatal consequences of uterine rupture: a population-based study of successive pregnancies in Sweden. BJOG 114:1208,r2007 Kayani SI, lfirevic Z: Uterine rupture after induction of labour in women with previous caesarean section. BJOG 112:45r1,r2005 Kieser E, Baskett TF: A 10-year population-based study of uterine rupture. Obstet Gynecol 100:749,r2002 Landon MB, Hauth Jc, Leveno KJ, et al: Maternal and perinatal outcomes associated with a trial of labor after prior cesarean delivery. N Engl J Med 351 :2581, 2004 Landon MB, Leindecker S, Spong CY, et al: he IvfFMU Cesarean Registry: factors afecting the success of trial of labor after previous cesarean delivery. Am J Obstet Gynecol 193:1016,r2005 Landon MB, Spong CY, Thon E, et al: Risk of


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Obstentrics_Williams. CY, et al: he IvfFMU Cesarean Registry: factors afecting the success of trial of labor after previous cesarean delivery. Am J Obstet Gynecol 193:1016,r2005 Landon MB, Spong CY, Thon E, et al: Risk of uterine rupture with a trial of labor in women with multiple and single prior cesarean delivery. Obstet Gynecol 108: 12, 2006 Lannon SM, Guthrie A, Vanderhoeven JP, et al: Uterine rupture risk after periviable cesarean delivery. Obstet Gynecol 125: 1 095, 2015 Lavin JP, DiPasquale L, Crane S, et al: A state-wide assessment of the obstetric, anesthesia, and operative team personnel who are available to manage the labors and deliveries and to treat the complications of women who attempt vaginal birth after cesarean delivery. Am J Obstet Gynecol 187:611, 2002 Leeman Uvl, Beagle M, Espey E, et al: Diminishing availability of trial of labor ater cesarean delivery in New Mexico hospitals. Obstet GynecoIr122:242, 2013 Lydon-Rochelle M, Holt VL, Easterling TR, et al: Risk of uterine rupture


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Obstentrics_Williams. et al: Diminishing availability of trial of labor ater cesarean delivery in New Mexico hospitals. Obstet GynecoIr122:242, 2013 Lydon-Rochelle M, Holt VL, Easterling TR, et al: Risk of uterine rupture during labor among women with a prior cesarean delivery. N Engl J Med 345:3,r2001 Macones GA, Cahill A, Pare E, et al: Obstetric outcomes in women with two prior cesarean deliveries: is vaginal birth after cesarean delivery a viable option? Am J Obstet GynecoIr192:1223, 2005a Macones GA, Cahill AG, Stamilio DM, et al: Can uterine rupture in patients attempting vaginal birth ater cesarean delivery be predicted? Am J Obstet Gynecol 195:1148,2006 Macones GA, Peipert J, Nelson DB, et al: Maternal complications with vaginal birth after cesarean delivery: a multicenter study. Am J Obstet Gynecol 193: 1656, 2005b Mankuta D, Mansour M, Alon SA: Ivlaternal and fetal morbidity due to abdominal adhesions after repeated cesarean section. Abstract No. 792, Am J Obstet Gynecol 208(1 Suppl):S332, 2013


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Obstentrics_Williams. 1656, 2005b Mankuta D, Mansour M, Alon SA: Ivlaternal and fetal morbidity due to abdominal adhesions after repeated cesarean section. Abstract No. 792, Am J Obstet Gynecol 208(1 Suppl):S332, 2013 Marshall NE, Fu R, Guise JM: Impact of multiple cesarean deliveries on maternal morbidity: a systematic review. Am J Obstet GynecoI205:262.e1, 2011 Martin IN, Perry KG, Roberts WE, et al: The care for trial of labor in the patients with a prior low-segment vertical cesarean incision. Am J Obstet Gynecol 177: 144, 1997 McMahon MJ, Luther ER, Bowes WA J r, et al: Comparison of a trial of labor with an elective second cesarean section. N Engl J Med 335:689, 1996 Mercer BM, Gilbert S, Landon MB, et al: Labor outcomes with increasing number of prior vaginal births after cesarean delivery. Obstet Gynecol 111:285,r2008 Metz TD, Stoddard GJ, Henry E, et al: Simple, validated vaginal birth after cesarean delivery prediction model for use at the time of admission. Obstet Gynecol 122:571,r2013 Miller


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Obstentrics_Williams. 111:285,r2008 Metz TD, Stoddard GJ, Henry E, et al: Simple, validated vaginal birth after cesarean delivery prediction model for use at the time of admission. Obstet Gynecol 122:571,r2013 Miller DA, Diaz FG, Paul RH: Vaginal birth after cesarean: a 10-year experience. Obstet GynecoIr84(2):255, 1994 Mozurkewich EL, Hutton EK: Elective repeat cesarean delivery versus trial of labor: a meta-analysis of the literature from 1989 to 1999. Am J Obstet Gynecol 183(5):1187,2000 Naji 0, Daemen A, Smith A, et al: Changes in cesarean section scar dimensions during pregnancy: a prospective longitudinal study. Ultrasound Obstet Gynecol 41(5):556, 2013a


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Obstentrics_Williams. Naji 0, Wynants L, Smith A, et al: Predicting successful vaginal birth after cesarean section using a model based on cesarean scar features examined using transvaginal sonography. Ultrasound Obstet Gynecol 41 (6):672, 2013b National Institutes of Health: Consensus Development Conference of Cesarean Childbirth, September 1980. NIH Pub No. 82-2067, Bethesda, NIH, 1981 National Institutes of Health Consensus Development Conference Panel: National Institutes of Health Consensus Development conference statement: Vaginl birth after cesarean: new insights. March 8-10, 2010. Obstet Gyneco1r115:12 9,20lO Nisenblat V, Barak S, Griness OB, et al: llaternal complications associated with multiple cesarean deliveries. Obstet Gynecol lO8:21, 2006 Osmundson SS, Garabedian MJ, Lyell OJ: Risk factors for classical hysterotomy by gestational age. Obstet Gynecol 122:845,r2013


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Obstentrics_Williams. Osser OV, Valentin L: Clinical importance of appearance of cesarean hysterotomy scar at transvaginal ultrasonography in nonpregnant women. Obstet Gynecol 117:525,r2011 Pauerstein CJ: Once a section, always a trial of labor? Obstet Gynecol 28:273, 1966 Pauerstein CJ, Karp L, Muher S: Trial oflabor after low segment cesarean section. S Med J 62:925, 1969 Peace man v!, Gersnoviez R, Landon MB, et al: he MFMU cesarean registry: impact of fetal size on trial of labor success for patients with previous cesarean for dystocia. Am J Obstet Gynecol 195:1127,2006 Quinones IN, Stamilio OM, Pare E, et al: he efect of prematurity on vaginal birth after cesarean delivery: success and maternal morbidity. Obstet Gynecol 105:519,r2005 Ramirez MM, Gilbert S, Landon MB, et al: Mode of delivery in women with antepartum fetal death and prior cesarean delivery. Am J Perinatol 27:825, 2010


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Obstentrics_Williams. Ramirez MM, Gilbert S, Landon MB, et al: Mode of delivery in women with antepartum fetal death and prior cesarean delivery. Am J Perinatol 27:825, 2010 Ravasia OJ, Brain PH, Pollard JK: Incidence of uterine rupture among women with mullerian duct anomalies who attempt vaginal birth after cesarean delivery. Am J Obstet Gynecol 7, 1999 Ravasia OJ, Wood SL, Pollard JK: Uterine rupture during induced trial of labor among women with previous cesarean delivery. Am J Obstet Gynecol 183:1176,r2000


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Obstentrics_Williams. Reyes-Ceja L, Cabrera R, Insfran E, et al: Pregnancy following previous uterine rupture: study of 19 patients. Obstet Gynecol 34:387, 1969 Ritchie EH: Pregnancy after rupture of the pregnant uterus: a report of 36 pregnancies and a study of cases reported since 1932. J Obstet Gynaecol Br Commonw 78:642, 1971 Roberge S, Demers S, Bergella V, et al: Impact of single-vs double-layer closure on adverse outcomes and uterine scar defect: a systematic review and metaanalysis. Am J Obstet Gynecol 211:453, 2014 Rodriguez MH, Masaki 01, Phelan JP, et al: Uterine rupture: are intrauterine pressure catheters useful in the diagnosis? Am J Obstet Gynecol 161 :666, 1989 Rosenstein MG, Kuppermann M, Gregorich SE, et al: Association between vaginal birth after cesarean delivery and primary cesarean delivery rates. Obstet Gynecol 122:lO10, 2013 Rossi AC, D'Addario V: Maternal morbidity following a trial of labor after cesarean section vs elective repeat cesarean delivery: a systematic review with


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Obstentrics_Williams. rates. Obstet Gynecol 122:lO10, 2013 Rossi AC, D'Addario V: Maternal morbidity following a trial of labor after cesarean section vs elective repeat cesarean delivery: a systematic review with metaanalysis. Am J Obstet Gynecol 199(3):224,2008 Royal College of Obstetricians and Gynaecologists: Birth after previous caesarean birth. Green-top Guideline No. 45, February 2007 Sachs BP, Koblin C, Castro A, et al: The risk of lowering the cesarean-delivery rate. N Engl J Med 340:5, 1999 Sciscione AC, Landon MB, Leveno KJ, et al: Previous preterm cesarean delivery and risk of subsequent uterine rupture. Obstet Gynecol 111 :648, 2008 Scott JR: Vaginal birth after cesarean delivery: a common-sense approach. Obstet Gynecol 118:342, 2011 Sheth SS: Results of treatment of rupture of the uterus by suturing. J Obstet Gynaecol Br Commonw 75:55, 1968 Shields M, Zwerling B, Cheng W: Outcomes of hospital versus out-ofhospital birth in vaginal birth after cesarean. Abstract No. 827. Am J Obstet Gynecol


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Obstentrics_Williams. J Obstet Gynaecol Br Commonw 75:55, 1968 Shields M, Zwerling B, Cheng W: Outcomes of hospital versus out-ofhospital birth in vaginal birth after cesarean. Abstract No. 827. Am J Obstet Gynecol 216:S474, 2017 Shipp TO, Zelop CM, Repke JT, et al: Interdelivery interval and risk of symptomatic uterine rupture. Obstet Gynecol 97: 175, 2001 Shipp TO, Zelop CM, Repke JT, et al: Intrapartum uterine rupture and dehiscence in patients with prior lower uterine segment vertical and transverse incisions. Obstet Gynecol 94:735, 1999 Shmueli A, Salman L, Nassie 01, et al: he intriguing association between epidural anesthesia and mode of delivery among women in trial of labor after cesarean delivery. Abstract No. 949. Am J Obstet Gynecol 216:S536, 2017 Silberstein T, Wiznitzer A, Katz M, et al: Routine revision of uterine scar after cesarean section: has it ever been necessary? Eur J Obstet Gynecol Reprod BioI 78:29, 1998


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Obstentrics_Williams. Silver M, Landon MB, Rouse 0], et al: Maternal morbidity associated with multiple repeat cesarean deliveries. Obstet Gynecol 207: 1226, 2006 Smith GC, Pell ]P, Cameron AD, et al: Risk of perinatal death associated with labor after previous cesarean delivery in uncomplicated term pregnancies. ]AMA 287:2684, 2002 Society for Matenal-Fetal Medicine: Counseling and management of women with prior classical cesarean delivery. Conremp OB/GYN 57(6):26, 2012 Society of Obstetricians and Gynaecologists of Canada: SOGC clinical practice guidelines. Guidelines for vaginal birth after previous caesarean birth. Number 155 (replaces guideline Number 147), February 2005. Intr] Gynaecol Obstet 89(3):319, 2005 Sondgeroth KE, Stout M], Tuuli MG, et al: Does uterine resting tone have any clinical value in trial oflabor (TOLAC)? Abstract No. 829. Am] Obstet Gynecol 216:5475, 201


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Obstentrics_Williams. Sondgeroth KE, Stout M], Tuuli MG, et al: Does uterine resting tone have any clinical value in trial oflabor (TOLAC)? Abstract No. 829. Am] Obstet Gynecol 216:5475, 201 Spong CY, Landon MB, Gilbert 5, et al: Risk of uterine rupture and adverse perinatal outcome at term after cesarean delivery. Obstet Gynecol 110:801, 2007 Srinivas SK, Stamilio OM, Stevens E], et al: Predicting failure of a vaginal birth attempt after cesarean delivery. Obstet Gynecol 109:800, 2007 Stamilio OM, DeFranco E, Pare E, et al: Short inrerpregnancy inrerval. Risk of uterine rupture and complications of vaginal birth after cesarean delivery. Obstet Gynecol 110, 1075,2007 Stanhope T, El-Nasher 5, Garrett A, et al: Prediction of uterine rupture or dehiscence during trial of labor after cesarean delivery: a cohort study. Abstract No. 821, Amr] Obstet Gynecol 208(1 Suppi):S343, 2013


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Obstentrics_Williams. Tahseen 5, Griiths M: Vaginal birth after two caesarean sections (VBAC-2)a systematic review with meta-analysis of success rate and adverse outcomes of VBAC-2 versus VBAC-1 and repeat (third) caesarean sections. B]OG 117:5,r2010 Tita AT, Landon MB, Spong CY, et al: Timing of elective repeat cesarean delivery at term and neonatal outcomes. N Engl ] Med 360(2): Ill, 2009 Traynor A], Aragon M, Ghosh 0, et al: Obstetric Anesthesia Workforce Survey: a 30-year update. Anesth Analg 122(6):1939, 2016 Uddin SFG, Simon E: Rates and success rates of trial oflabor ater cesarean delivery in the United States, 1990-2009. Maten Child Health] 17:1309,2013 Usta 1M, Hamdi MA, Abu Musa A, et al: Pregnancy outcome in patients with previous uterine rupture. Acta Obstet Gynecol 86: 172, 2007 Usta 1M, Hobeika EM, Abu-Musa A, et al: Placenra previa-accreta: risk factors and complications. Am] Obstet Gynecol 193:1045,2005


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Obstentrics_Williams. Usta 1M, Hobeika EM, Abu-Musa A, et al: Placenra previa-accreta: risk factors and complications. Am] Obstet Gynecol 193:1045,2005 Varner MW, Thon E, Spong CY, et al: Trial oflabor after one previous cesarean delivery for multifetal gestation. Obstet Gynecol 110:814, 2007 Weill Y, Pollack RN: The eicacy and safety of external cephalic version after a previous caesarean delivery. Aust N Z ] Obstet Gynaecol 57(3):323, 20r17 Wen SW, Huang L, Liston R, et al: Severe maternal morbidity in Canada, 1991-2001. CMA] 173:759,r2005 Wing DA, Lovett K, Paul RH: Disruption of prior uterine incision following misoprostol for labor induction in women with previous cesarean delivery. Obstet Gynecol 91 :828, 1998 Wing DA, Paul RH: Vaginal birth after cesarean section: selection and management. Clin Obstet GynecoIr42:836, 1999


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Obstentrics_Williams. Wing DA, Paul RH: Vaginal birth after cesarean section: selection and management. Clin Obstet GynecoIr42:836, 1999 Zelop CM, Shipp TO, Repke ]T, et al: Outcomes of trial of labor following previous cesarean delivery among women with fetuses weighing >4000 g. Am] Obstet Gynecol 185:903,2001 Zelop CM, Shipp TO, Repke ]T, et al: Uterine rupture during induced or augmented labor in gravid women with one prior cesarean delivery. Am ] Obstet Gynecol 181r:882, 1999 The Newborn TRANSITION TO AIR BREATHING .................. 606 CARE IN THE DELIVERY ROOM .................... 607 EVALUATION OF NEWBORN CONDITION ............ 610 PREVENTIVE CARE.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 613 ROUTINE NEWBORN CARE ....................... 614 Normaly the newy born child begins to cry almost immediatey ater its exit from the vulva. This act indicates the establishment of respiration, which is accompanied by important modications in the circulatory system.


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Obstentrics_Williams. -J. Whitridge Williams (1903) In most instances at delivery, the newborn is healthy and vigorous, but at times, special care may be needed. For this reason, the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists (20 17b) recommend that every birth should be attended by at least one qualified individual. This person should be skilled in the initial steps of newborn care and positive-pressure ventilation, and their only responsibility is management of the newborn. his usually is a pediatrician, nurse practitioner, anesthesiologist, nurse anesthetist, or specially trained nurse. However, in their absence, the responsibility for neonatal resuscitation falls to the obstetrical attendant. hus, obstetricians should be well versed in measures for immediate care of the newborn.


Obstentrics_Williams

Obstentrics_Williams. The number and qualiications of personnel who attend the delivery will vary depending on the anticipated risk, the number of babies, and the hospital setting. A qualiied team with full resuscitation skills should be present for high-risk deliveries and immediately available for every resuscitation (Wyckof, 2015). This team should not be on call at home or in a remote area of the hospital. Moreover, team training through frequent simulation practice is recommended for all who may be called to attend deliveries (Perlman, 2015).


Obstentrics_Williams

Obstentrics_Williams. Immediately following birth, the newborn must promptly convert from placental to pulmonary gas exchange. Pulmonary vascular resistance must fall, pulmonary perfusion must rapidly rise, and unique fetal vascular shunts must begin to close to separate the systemic and pulmonary circulations (Rudolph, 1979). These shunts include the patent ductus arteriosus and patent foramen ovale, described in Chapter 7 (p. 129). Lung aeration is not only critical for pulmonary gas exchange. Recent studies suggest that it is signiicantly responsible for initiating cardiovascular changes at birth (Hooper, 2016).


Obstentrics_Williams

Obstentrics_Williams. In utero, the fetal lungs are illed with amnionic luid, which must be cleared quickly for air breathing. This clearance occurs through various means, and the contributions of these mechanisms may depend on gestational age and mode of delivery. First, a large release of fetal adrenaline late in labor stimulates pulmonary epithelial cells to stop secreting and instead to start reabsorbing lung liquid as a result of sodium-channel activation (te Pas, 2008). The contribution of this mechanism is unlikely to be major, as blockade of the receptors for sodium channel activation reduces or delays but does not prevent lung liquid clearance at birth (O'Brodovich, 1990).


Obstentrics_Williams

Obstentrics_Williams. As a second method, mechanical forces aid lung fluid clearance during labor. Early reports described compression of the fetal thorax and abdomen as they passed through the birth canal leading to lung liquid expulsion (Karl berg, 1962; Saunders, 1978). By this mechanism, up to a third of lung liquid is expelled in a jet of luid from the nose and mouth once the respiratory tract is exposed to the lower outside pressure. The Newborn 607 However, it may be that uterine contractions force a change in fetal posture leading to compression of the thorax and increased intrathoracic pressures. his prompts expulsion of lung liquid early in labor more so than the "vaginal squeeze" theory (Lines, 1997; te Pas, 2008; Vyas, 1981).


Obstentrics_Williams

Obstentrics_Williams. In a third mechanism, a significant amount of lung liquid is cleared after birth (Hooper, 2016). In animal studies, most lung aeration occurs during inspiration-within three to ive breaths after birth. But, no liquid clears between breaths (Hooper, 2007). Speciically, the transpulmonary pressure gradient during inspiration promotes movement of fluid into the interstitial tissue. From here, it is gradually cleared, probably by the pulmonary circulation and lymphatic vessls. It is possible for lung interstitial tissue pressure to rise to a point that luid can actually move back into the airspaces during expiration unless positive end-expiratory pressure opposes liquid reentry (Siew, 2009a,b). This may be a contributing factor in the development of transient tachypnea of the newborn.


Obstentrics_Williams

Obstentrics_Williams. As fluid is replaced by air, compression of the pulmonary vasculature is reduced considerably, and in turn, resistance to blood flow is lowered. With the fall in pulmonary arterial blood pressure, the ductus arteriosus normally closes. High, negative intrathoracic pressures are required to permit the initial entry of air into the fluid-illed alveoli. Normally, from the irst breath after birth, progressively more residual air accumulates in the lung. And, with each successive breath, lower pulmonary opening pressure is required. In the normal mature newborn, by approximately the ifth breath, pressurevolume changes achieved with each respiration are very similar to those of the adult. hus, the breathing pattern shifts from shallow episodic inspirations characteristic of the fetus to regular, deeper inhalations (Chap. 17, p. 333).


Obstentrics_Williams

Obstentrics_Williams. As a last mechanism, surfactant, which is synthesized by the type II pneumocytes, lowers alveolar surface tension and helps maintain lung inlation by preventing alveolar collapse. Insuficient surfactant, which is common in preterm neonates, leads promptly to respiratory distress syndrome (Chap. 34, p. 636). In utero, umbilical venous retun is the main source of preload for the left ventricle, particularly as fetal pulmonary blood flow is very low due to high pulmonary vascular resistance and is unable to provide suicient venous return to maintain left ventricular output (Hooper, 2015).


Obstentrics_Williams

Obstentrics_Williams. Clamping the umbilical cord reduces preload for the left ventricle and thus reduces cardiac output. Until the lungs aerate and pulmonary blood low increases, the reduced cardiac output will manifest as bradycardia. If cord clamping is delayed until after the lungs have aerated, the transition is smoother and cardiac ouput does not fall (Bhatt, 2013). This understanding has led to interest in delayed (physiological) cord clamping, especially if it can be done after successful inflation of the lung. Randomized trials are currently underway. The International Liaison Committee on Resuscitation (ILCOR) updated its scientiic review for neonatal delivery room care and resuscitation (Perlman, 2015). The ILCOR scientiic review is used by the American Academy of Pediatrics and the American Heart Association to develop the neonatal resuscitation guidelines for North America (Wyckof, 2015).


Obstentrics_Williams

Obstentrics_Williams. Before and during delivery, careful consideration must be given to several determinants of neonatal well-being. hese include: (1) maternal health status; (2) prenatal complications, including any suspected fetal malformations; (3) gestational age; (4) labor complications; (5) duration of labor and ruptured membranes; (6) type and duration of anesthesia; (7) diiculty of delivery; and (8) medications given during labor and their dosages, administration routes, and timing.


Obstentrics_Williams

Obstentrics_Williams. When risk factors are present, neonatal resuscitation providers should be present for the delivery. This team readies equipment, ensures that adequate personnel are present, delegates roles and responsibilities, and considers contingency plans to stabilize the newborn. Four questions a neonatal provider will ask pertain to expected gestional age, amnionic fluid color, fetal number, and additional fetal risks. Several conditions are associated with a nonvigorous presentation. These may include immaturity, hypoxemia or acidosis from any cause, sepsis syndrome, recent drugs administered to the mother, and central nervous system developmental abnormalities. Those related to the respiratory tract are lung abnormalities, upper airway obstruction, pneumothorax, and meconium aspiration.


Obstentrics_Williams

Obstentrics_Williams. Ideally, obstetrical and pediatric teams discuss plans regarding umbilical cord management. Delayed cord clamping provides transfusion of placental blood to the newborn. In term infants, delay of cord clamping by 30 to 60 seconds raises hemoglobin levels at birth, improves iron stores during infancy, and enhances neurodevelopment at 4 years of age (Katheria, 2017). As discussed in Chapter 33 (p. 625), the only reported negative outcome of delayed cord clamping is hyperbilirubinemia, leading to a higher rate of phototherapy (American College of Obstetricians and Gynecologists, 2017a). In preterm neonates, delayed cord clamping reduces rates of blood transfusion, intraventricular hemorrhage, and necrotizing enterocolitis.


Obstentrics_Williams

Obstentrics_Williams. Delayed cord clamping should be performed in preterm and term newborns who do not require resuscitation at birth (American Academy of Pediatrics, 2017 a; American College of Obstetricians and Gynecologists, 2017a; Perlman, 2015). here should be no delay if a newborn requires resuscitation or if the placental circulation is disrupted by abruption, cord avulsion, or bleeding placenta previa or vasa previa. Approximately 10 percent of newborns require some degree of active resuscitation to stimulate breathing, and 1 percent need extensive care. Perhaps not coincidentally, the risk of death for newborns delivered at home compared with those delivered in hospitals is increased two-to threefold (American College of Obstetricians and Gynecologists, 2017 d). When deprived of adequate gas exchange, either before or after birth, neonates demonstrate a well-deined sequence of


Obstentrics_Williams

Obstentrics_Williams. When deprived of adequate gas exchange, either before or after birth, neonates demonstrate a well-deined sequence of FIGURE 32-1 Physiological changes associated with primary and secondary apnea in the newborn. bpm = beats per minute; HR = heart rate; MAP mean arterial pressure. (Adapted with permission from Kattwinkel J: Textbook of Neonatal Resuscitation, 6th ed. Elk Grove Village, American Academy of Pediatrics and American Heart Association, 2010.) events leading to apnea (Fig.


Obstentrics_Williams

Obstentrics_Williams. With oxygen deprivation and carbon dioxide (C02) elevation, there is a transient period of rapid breathing, and if it persists, breathing stops, which is termed primay apnea. This stage is accompanied by a fall in heart rate and loss of neuromuscular tone. Simple stimulation will usually reverse primary apnea. If oxygen deprivation and asphyxia persist, however, the newborn will develop deep gasping respirations, followed by seconday apnea. This latter stage is associated with a further decline in heart rate, fall in blood pressure, and loss of neuromuscular tone. Neonates in secondary apnea will not respond to stimulation and will not spontaneously resume respiratory eforts. Unless ventilation is assisted, death follows. Clinically, primary and secondary apneas are indistinguishable, and thus, secondary apnea must be assumed. And, when a response to stimulation is not immediate, resuscitation with efective ventilation of the apneic newborn must be started quickly.


Obstentrics_Williams

Obstentrics_Williams. Immediately after birth and usually during the delay for umbilical cord clamping, newborn tone, respiratory efort, and heart rate are evaluated (Fig. 32-2). :Most term neonates are vigorous by 10 to 30 seconds after birth (Ersdal, 2012). For these, initial steps of warming the newborn can be done on the mother's chest or abdomen. Direct skin-to-skin contact with the mother and drying and covering the newborn with a warm blanket will help maintain euthermia (36.5 to 37.5°C). A vigorously crying newborn does not require routine oral suctioning (Carrasco, 1997; Gungor, 2006). Instead, bulb suctioning to remove secretions is best reserved for those who cannot clear secretions on their own due to apnea or copious secretions. Additional routine care steps include drying, gentle stimulation by rubbing the newborn's back, and continued observation during the transition period.


Obstentrics_Williams

Obstentrics_Williams. If not vigorous or if preterm, the neonate is carried to a prewarmed radiant warmer for the initial newborn care steps. The initial wet birth blanket is removed to allow newborn drying. Cold stress is associated with multiple neonatal morbidities and mortality. Preterm infants are particularly vulnerable, and special steps to maintain euthermia include providing a warmer delivery room (>25°C), covering the neonatal head with either a plastic or wool hat, application of polyethylene plastic "ponchos" or wraps to slow evaporative heat losses, use of chemically activated thermal mattresses to reduce conductive heat loss, and administration of warm, humidified respiratory gases during respiratory stabilization (Perlman, 2015).


Obstentrics_Williams

Obstentrics_Williams. At the radiant warmer, newborns must be positioned to maximally open the airway, with mild extension of the neck. If the newborn is apneic or has copious secretions that it cannot clear, a bulb syringe or suction catheter may be used to clear the mouth and then the nose. Routine intubation and suctioning of meconium-stained amnionic luid is no longer recommended for the nonvigorous newborn (American College of Obstetricians and Gynecologists, 2017b; Perlman, 2015). Intubation and suction are reserved for suspected airway obstruction. After completion of the initial stabilization steps, apnea, gasping respirations, or heart rate � 100 beats per minute (bpm) should prompt immediate administration of positivepressure ventilation with room air (Fig. 32-3). his should be started by 60 seconds of life, if not sooner, once the initial steps are completed.


Obstentrics_Williams

Obstentrics_Williams. Assisted ventilation by facemask at a rate of 40 to 60 breaths per minute is recommended. Oxygen saturation is monitored by pulse oximetry. Supplemental oxygen can be given in graduated, rising percentages to maintain oxygen saturation values within a normal range per minute of life. Adequate ventilation is best indicated by an improved heart rate. Colorimetric end-tidal carbon dioxide (ETC02) monitoring placed between the positive-pressure device and facemask serves as a helpful adjunct for detection of successful gas exchange during mask ventilation (Weiner, 2016).


Obstentrics_Williams

Obstentrics_Williams. If the heart rate remains � 100 bpm after 5 to 10 positive pressure breaths, the attempted ventilation is inadequate and corrective steps must be taken. These can be remembered by the pneumonic MR. SOPA (Table 32-1). The two most common problems are mask leak due to an inefective seal and malposition of the airway (Schmolzer, 2011). If corrective steps do not improve the heart rate, either intubation with an endotracheal tube or placement of a laryngeal mask airway is required.


Obstentrics_Williams

Obstentrics_Williams. If mask ventilation is inefective or prolonged, an alternative airway is placed. For tracheal intubation, a laryngoscope with a straight blade-size 0 for a preterm newborn and size 1 for a term neonate-is used. Gentle cricoid pressure may be useful. An increasing heart rate and ETC02 detection after several breaths are the primary methods of conirming intubation of the trachea and not the esophagus. One can also look for symmetrical chest wall motion; auscultate for equal breath sounds, especially in the axillae; and auscultate for the absence of breath sounds or gurgling over the stomach. The Newborn 609


Obstentrics_Williams

Obstentrics_Williams. The Newborn 609 Once in place, the tube is used for tracheal suctioning only for a suspected obstructed airway. Otherwise, an appropriate positive-pressure device is attached to the endotracheal tube. Air pufs are delivered at a rate of 40 to 60 per minute with a force adequate to stabilize the heart rate. In term infants, opening pressures of 30 to 40 cm H20 typically will expand the alveoli without causing barotrauma. Once the lung is inflated, less pressure is typically needed (20 to 25 cm H20). For preterm infants, pressures of 20 to 25 cm Term? Good tone? Breathing/crying? H20 are typically used. An increase in heart rate and peripheral oxygen saturation (Sp02) levels within acceptable ranges reflect a positive response.


Obstentrics_Williams

Obstentrics_Williams. Term? Good tone? Breathing/crying? H20 are typically used. An increase in heart rate and peripheral oxygen saturation (Sp02) levels within acceptable ranges reflect a positive response. FIGURE 32-2 Algorithm for resuscitation of the newborn based on the International Liaison Committee on Resuscitation scientific review and recommended by the American Academy of Pediatrics and American Heart Association (Perlman, 2015; Wyckoff, 2015). bpm = beats per minute; CPAP = continuous positive airway pressure; ECG = electrocardiogram; ETT = endotracheal tube; HR = heart FIGURE 32-3 Correct use of bag-and-mask ventilation. The head rate; IV = intravenous; PPV = positive-pressure ventilation; Sp02= should be in a sniffing position with the tip of the nose pointing to peripheral oxygen saturation; UVC = umbilical venous catheter. the ceiling. The neck should not be hyperextended.


Obstentrics_Williams

Obstentrics_Williams. Epinephrine measures (American Academy of Pediatrics, 2017). s shown in Table 32-2, each of five easily identiiable characteristics Intravenously administered epinephrine is indicated if the heart heart rate, respiratory efort, muscle tone, relex irritability, andrate remains ;60 bpm after adequate ventilation and chest color-is assessed and assigned a value of 0, 1, or 2. In the curcompressions. The recommended intravenous dose is 0.01 to rently recommended expanded form, concurrent resuscitation 0.03 mg/kg. Epinephrine may be given through the endotracheal interventions are also recorded over time. he total score, based on tube if venous access has not been established, but its action is the sum of the five components, is determined in all neonates at 1less reliable (Kapadia, 2017). If given through the endotracheal and 5 minutes ater delivery. In those with a score <7, the scoretube, higher doses are employed-0.05 to 0.1 mg/kg.


Obstentrics_Williams

Obstentrics_Williams. may be calculated at urther 5-minute intervals until a 20-minute Discontinuation of Resuscitation Apgar score is assigned or resuscitation eforts are halted. In an analysis of more than 150,000 newborns delivered at ILCOR concludes that it is reasonable to discontinue resusciParkland Hospital, Casey and associates (2001 b) assessed thetative eforts for a neonate who remains without a heartbeat signiicance of the 5-minute score for predicting survival durdespite at least 10 minutes of continuous and adequate resusciing the first 28 days of life. They found that in term neonates,tative eforts. Notably, the decision to continue or discontinue the risk of neonatal death was approximately 1 in 5000 for resuscitative eforts must be individualized (Perlman, 2015).


Obstentrics_Williams

Obstentrics_Williams. those with Apgar scores of 7 to 10. his risk compares with a mortality rate of 25 percent for term newborns with 5-minute scores ;3. Low 5-minute scores were comparably predictive of neonatal death in preterm neonates. These investigators con • Apgar Score cluded that the Apgar scoring system remains relevant for the he scoring system described by Dr. Virginia Apgar in 1953 prediction of neonatal survival. remains a useul clinical tool to classiY newborn health immeThere have been attempts to use Apgar scores to define diately after birth and to assess the efectiveness of resuscitative asphxial injury and to predict subsequent neurological TABLE 32-2. 20-Minute Expanded Apgar Score Respiration Absent Weak cry; hypo-Good, crying Comments: Resuscitation CPAP = continuous positive airway pressure; En = endotracheal tube; PPV = positive-pressure ventilation. Data from Weiner, 2016.


Obstentrics_Williams

Obstentrics_Williams. Comments: Resuscitation CPAP = continuous positive airway pressure; En = endotracheal tube; PPV = positive-pressure ventilation. Data from Weiner, 2016. outcome-uses for which the Apgar score was never intended (Chap. 33, p. 624). Such associations are diicult to mea sure with reliability given that both asphyxial injury and low Apgar scores are infrequent outcomes. For example, according to United States birth certiicate records for 2010, only 1.8 percent of newborns had a 5-minute score below 7 (Martin, 2012). Similarly, in a population-based study of more than 1 million term newborns in Sweden between 1988 and 1997, the incidence of 5-minute Apgar scores of �3 approximated 2 per 1000 (Thorngren-Jerneck, 2001).


Obstentrics_Williams

Obstentrics_Williams. Previously, many groups established erroneous definitions of asphyxia based solely on low Apgar scores. hese prompted the American College of Obstetricians and Gynecologists and American Academy of Pediatrics (2017f) to issue a series of joint opinions with important caveats regarding Apgar score limitations. Certain elements of the Apgar score are partially dependent on the physiological maturity of the newborn, and a healthy, preterm neonate may receive a low score only because of immaturity. Other influencing factors include fetal malformations, maternal medications, and infection. Therefore, it is inappropriate to use an Apgar score alone to diagnose asphyxia. Moreover, the Apgar score alone cannot establish hypoxia as the cause of cerebral palsy, as discussed in Chapter 33 (p. 624).


Obstentrics_Williams

Obstentrics_Williams. Blood taken from umbilical vessels may be used for acid-base studies to assess the metabolic status of the neonate. Blood collection is performed following delivery by immediately isolating a 10-to 20-cm segment of cord with two clamps placed near the neonate and another two clamps positioned nearer the placenta. The cord is then cut between the two proximal clamps and then the two distal clamps (Blickstein, 2007).


Obstentrics_Williams

Obstentrics_Williams. Arterial blood is drawn from the isolated cord segment into a 1-to 2-mL commercially prepared plastic syringe containing lyophilized heparin or a similar syringe that has been flushed with a heparin solution containing 1000 U/mL. Once sampling is completed, the needle is capped and the syringe transported, on ice, to the laboratory. Although eforts should be made for prompt transport, neither the pH nor partial pressure of CO2 (pC02) values change significantly in blood kept at room temperature for up to 60 minutes (Lynn, 2007). Mathematical models have been developed that allow reasonable prediction of birth acid-base status in properly collected cord blood samples analyzed as late as 60 hours after delivery (Chauhan, 1994). Acid-base measurements can show signiicant variances between diferent analyzing devices (vlokarami,r2012).


Obstentrics_Williams

Obstentrics_Williams. he fetus produces both carbonic and organic acids. Carbonic acid (H2C03) is formed by oxidative metabolism of CO2. he fetus usually rapidly clears CO2 through the placental circulation. If CO2 clearance is lowered, then carbonic acid levels rise. This often follows impaired placental exchange. When H2C03 The Newborn 61 1 rently rise, the result is respiratoy acidemia.


Obstentrics_Williams

Obstentrics_Williams. The Newborn 61 1 rently rise, the result is respiratoy acidemia. In contrast, organic acids primarily include lactic and 3-hydroxybutyric acids. Levels of these increase with persistent placental exchange impairment, and they result from anaero bic glycolysis. These organic acids are cleared slowly from fetal blood. When they accumulate, without a concurrent increase in H2C03, the result is metabolic acidemia. With the develop ment of metabolic acidemia, bicarbonate (HC03 -) levels drop because it is used to bufer the organic acid. A rise in H2C03 concentrations accompanied by greater organic acid levels, relected by decreased HC03 -levels, causes mixed respiratoy metabolic acidemia.


Obstentrics_Williams

Obstentrics_Williams. In the fetus, respiratory and metabolic acidemia and ultimately tissue acidosis are most likely part of a progressively worsening continuum. his is diferent from adult pathophysiology, in which distinct conditions result either in respiratory acidosis-for example, pulmonary disease, or in metabolic acidosis-for example, diabetes. In the fetus, the placenta serves as both the lungs and, to a certain degree, the kidneys. One principal cause of fetal acidemia is a drop in uteroplacental perfusion. This creates retention of CO2, that is, respiratory acidemia, and if protracted and severe enough, yields a mixed or metabolic acidemia. Assuming that maternal pH and blood gases are normal, the actual pH of fetal blood is dependent on the proportion of carbonic and organic acids and the amount of bicarbonate, which is the major bufer in blood. This can best be illustrated by the Henderson-Hasselbalch equation: [base]pH = pK + Iog -or, pH = pK + Iog


Obstentrics_Williams

Obstentrics_Williams. For clinical purposes, HC03-represents the metabolic component and is reported in mEq/L. The H2C03 concentration reflects the respiratory component and is reported as the pC02 in mm Hg. Thus: The result of this equation is a pH value. Because pH is a logarithmic term, it does not give a linear measure of acid accumulation. For example, a change in hydrogen ion concentration associated with a fall in pH from 7.0 to 6.9 is almost twice that which is associated with a fall in pH from 7.3 to 7.2. For this reason, the change in base-termed delta base-ofers a more linear measure of the degree of accumulation of metabolic acid (Armstrong, 2007). The delta base is a calculated number used as a measure of the change in bufering capacity of bicarbonate (HC03 -). he formula for calculating the base excess (BE) is as follows:


Obstentrics_Williams

Obstentrics_Williams. BE = 0.02786 X pC02 X lO(pH -6.,1) X 13.77 X pH -124.58 32-4 is a nomogram developed from which these can be calculated if only two parameters are known. For example, the HC03 -concentration declines with a metabolic acidemia as it is consumed to maintain a normal pH. A base deicit develops when the HC03-concentration drops below 6.8 reported for preterm neonates (Dick8 pH 015 ? ,:00 ,0ED 70 inson, 1992; Ramin, 1989; Riley, 7.2 7.1 Fetal oxygenation and pH generally decline during the course of normal 7.0 labor. Normal umbilical cord blood pH and blood gas values at delivery 6.9 60 in term newborns are summarized in


Obstentrics_Williams

Obstentrics_Williams. Table 32-3. Similar values have been 6.7 1993). he lower limits of normal pH in the newborn have been found to range from 7.04 to 7.10 (horp, 6.6 1996). Thus, these values should be 6 considered to deine neonatal acidemia. Even so, most fetuses will tol erate intrapartum acidemia with a 110 pH as low as 7.00 without incurring neurological impairment (Freeman, 1988; Gilstrap, 1989). That said, in FIGURE 32-4 Nomogram for determining the delta base. (Adapted with permission from Siggaarda study of newborns with a pH <7.0 Anderson 0: Blood acid-base alignment nomogram, Scand J (lin Lab Invest. 1963;15:21o1-7.) from Parkland Hospital, there were TABLE 32-3. Umbilical Cord Blood pH and Blood Gas Values in Normal Term Newborns


Obstentrics_Williams

Obstentrics_Williams. TABLE 32-3. Umbilical Cord Blood pH and Blood Gas Values in Normal Term Newborns Ramin, 1989a Riley, 1993b Kotaska, 201 Ob Kotaska, 2010e pH 7.28 (0.07) 7.27 (0.069) 7.26 (7.01n-7.39) 7.3 (7.05-7.39) Pco2 (mm Hg) 49.9 (14.2) 50.3(11n.1) 51 (30.9-85.8) 54 (37.5-79.5) HC03 -(mEq/L) 23.1 (2.8) 22.0 (3.6) Base excess (mEq/L) -3.6 (2.8) -2.7 (2.8) pH 7.34 (0.063) 7.31 (7.06-7.44) 7.34 (7.10-7.42) PC02 (mm Hg) 40.7 (7.9) 41 (24.9-70.9) 44 (29.1n-70.2) HC03 -(mEq/L) 21.4 (2.5) Base excess (mEq/L) -2.4 (2) aNewborns of selected women with uncomplicated vaginal deliveries. bNewborns of unselected women with vaginal deliveries. (Data shown as mean (SO). dOata shown as range with 2.5 or 97.5 percentile. eCesarean delivery-labor not stated. From Centers for Disease Control and Prevention, 201n2; Watson, 2006.


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Obstentrics_Williams. (Data shown as mean (SO). dOata shown as range with 2.5 or 97.5 percentile. eCesarean delivery-labor not stated. From Centers for Disease Control and Prevention, 201n2; Watson, 2006. normal levels, and a base excess occurs when HC03 -values are above normal. Importantly, a mixed respiratory-metabolic acidemia with a large base deicit and a low HC03 -, for example 12 mmollL, is more often associated with a depressed neonate than is a mixed acidemia with a minimal base deficit and a more nearly normal HC03 -level.


Obstentrics_Williams

Obstentrics_Williams. The Newborn 61 3 inordinate proportions of neonatal deaths-8 percent, intensive care admissions-39 percent, intubations-14 percent, and seizures-13 percent (Goldaber, 1991). And, in a study from Oxford of more than 51,000 term newborns, the incidence of neonatal encephalopathy in those with a birth pH <7.0 was 3 percent (Yeh, 2012). Even those with who had normalrS-minute Apgar scores but an arterial cord pH values <7.0 had a significantly higher risk of morbidity that included respiratory distress, neonatal intensive care unit admission, and sepsis (Sabol, 2016). The speed of acidemia resolution after birth is associated with outcome (Casey, 2001a). Acute interruption in placental gas exchange is accompanied by subsequent CO2 retention and respiratory acidemia. The most common antecedent factor is transient umbilical cord compres sion. Generally, respiratory acidemia is not harmful to the fetus (Low, 1994).


Obstentrics_Williams

Obstentrics_Williams. he degree to which pH is afected by pC02-the respira tory component of the acidosis-can be calculated. First, the upper normal neonatal pC02 of about 50 mm Hg is subtracted from the cord blood gas pC02 value. Each additional 10 mm Hg pC02 increment will lower the pH by 0.08 units (Eisen berg, 1987). hus, in a mixed respiratory-metabolic acidemia, the benign respiratory component can be calculated. As an example, acute cord prolapse during labor prompts cesarean delivery of a neonate 20 minutes later. The umbilical artery blood gas pH was 6.95 and the pC02 was 90 mm Hg. The degree to which the cord compression and subsequent impair ment of CO2 exchange afected the pH is calculated using the relationship given earlier and shown below. To correct pH: (40 -10) X 0.08 = 0.32; 6.95 + 0'.32 = 7.27 Therefore, the pH before cord prolapse was approximately 7.27, well within normal limits. Thus, the low pH resulted from respiratory acidosis.


Obstentrics_Williams

Obstentrics_Williams. The fetus begins to develop metabolic acidemia when oxygen deprivation is suiciently long and severe to require anaerobic metabolism for cellular energy needs. Low and associates (1997) defined fetal acidosis as a base deicit ::12 mmoUL, and severe fetal acidosis as a base deicit ::16 mmoUL. In the Parkland study of more than 150,000 newborns cited earlier, metabolic acidemia was defined using umbilical cord blood gas thresholds that were two standard deviations below the mean (Casey, 2001 b). Thus, metabolic acidemia was an umbilical artery blood pH <7.00 accompanied by a pC02 ;76.3 mm Hg, with higher values indicating a respiratory component; HC03-concentration ;17.7 mmoUL; and base deficit ::10.3 mEq/L. From the standpoint of possible neurological injury, the American College of Obstetricians and Gynecologists (2014) defines metabolic acidosis as umbilical arterial pH <7.0 and a base deficit ::12 mmoUL.


Obstentrics_Williams

Obstentrics_Williams. Metabolic acidemia is associated with a high rate of multiorgan dysfunction. In rare cases, such hypoxia-induced metabolic logical impairment-hypoxic-ischemic encephalopathy (Chap. 33, p. 621). In fact, a fetus without such acidemia cannot by definition have sufered recent hypoxic-induced injury. hat said, severe metabolic acidosis is poorly predictive of subse quent neurological impairment in the term neonate (King, 1998; Socol, 1994). In very-Iow-birthweight neonates, that is, those < 1000 g, newborn acid-base status may be more closely linked to intraventricular hemorrhage and possibly long-term neurological outcome (Lavrijsen, 2005; Salhab, 2005; Victory, 2003).


Obstentrics_Williams

Obstentrics_Williams. Casey and coworkers (2001 b) described the association between metabolic acidemia, low Apgar scores, and neonatal death in term and preterm newborns. Regarding term neonates, the risk of neonatal death was more than 3200-fold greater in term neonates with metabolic acidemia and 5-minute scores ;3 compared with those with a 5-minute Apgar score ::7. In some centers, cord gas analysis is performed in all neonates at birth (Casey, 2001 b; Sabol, 2016). Cost-efectiveness analysis potential cost savings (White, 2010, 2016). It seems reasonable of cesarean delivery for fetal compromise, abnormal fetal heart rate tracing, fever, and low 5-minute Apgar score. Multifetal gestation and severely growth-restricted fetuses are others. are poorly predictive of either immediate or long-term adverse neurological outcome, they provide the most objective evidence of the fetal metabolic status at birth.


Obstentrics_Williams

Obstentrics_Williams. are poorly predictive of either immediate or long-term adverse neurological outcome, they provide the most objective evidence of the fetal metabolic status at birth. Ophthalmia neonatorum is mucopurulent conjunctivitis of newborns. Some form of conjunctivitis afects 1 to 12 percent of all neonates, and gonococcal and chlamydial infections are among the most common (Zuppa, 201r1).


Obstentrics_Williams

Obstentrics_Williams. Neisseria gonorrhoeae infection acquired at birth was a common cause of childhood blindness in the past. However, the practice of instilling a I-percent ophthalmic solution of silver nitrate largely eliminated this. Various other antimicrobial agents have also proven efective, and gonococcal prophylaxis is now mandatory for all neonates in most states (American Academy ofPediatrics, 20 17b). Forprophyxis soon ater delivery, recommendations include a single application of either I-percent silver nitrate solution or 0.5-percent erythromycin ointment. In North America, a previously used I-percent tetracycline ophthalmic ointment is no longer available (Mabry-Hernandez, 2010; Moore, 2015). For a neonate born to a mother with untreated gonorrhea, treatment of presumptive neonatal gonococcal conjunctivitis is a single ceftriaxone dose, 100 mg/kg, given either intramuscularly or intravenously. Before treatment, testing for both gonococcal and chlamydia infections should be obtained.


Obstentrics_Williams

Obstentrics_Williams. With chamydial conjunctivitis, adequate neonatal prophylaxis is complex. Ideally, prenatal screening and treatment for Chamydia trachomatis obviates conjunctival infection (Hammerschlag, 2011). In neonates delivered vaginally of mothers with an active chlamydial infection, 12 to 25 percent will develop conjunctivitis up to 20 weeks ater birth (Teoh, 2003). Prophyactic topical eye treatments do not reliaby reduce the incidence of chlamydial conjunctivitis. In a study from Kenya, 2.5-percent povidone-iodine solution was reported to be superior to either I-percent silver nitrate solution or 0.5-percent erythromycin ointment in preventing chlamydial conjunctivitis (Isenberg, 1995). In another study from Iran, povidone-iodine eye drops were twice as efective in preventing clinical conjunctivitis as erythromycin drops-9 versus 18 percent failure rate, respectively (Ali, 2007).


Obstentrics_Williams

Obstentrics_Williams. Conjunctivitis in a newborn up to age 3 months should prompt consideration for chlamydial infection (Moore, 2015). Treatment for pediatric chlamydial infection is with oral azithromycin for 5 days or oral erythromycin for 14 days. Routine immunization with thimerosal-free vaccine against hepatitis B before hospital discharge is standard practice for all medically stable newborns with birthweights greater than 2000 g (merican Academy of Pediatrics, 20 17b). If the mother is seropositive for hepatitis B surface antigen, then the neonate is also passively immunized with hepatitis B immune globulin. As discussed in Chapter 55 (p. 1064), some advocate treatment of high-risk or even all seropositive women with antiviral nucleoside or nucleotide analogues during pregnancy to minimize fetal transmission (Dusheiko, 2012; Tran, 2012).


Obstentrics_Williams

Obstentrics_Williams. his virus is primarily spread by mosquito bites. Infection is asymptomatic in most people but can cause severe birth defects (Chap. 64, p. 1219). Screening begins with an interrogation for recent travel to endemic areas. For women at risk, serological screening is then completed. All newborns of mothers who have laboratory evidence of Zika virus infection during pregnancy should receive a comprehensive examination, a neurological assessment, postnatal head ultrasound, standard newborn hearing screen before hospital discharge, and Zika virus laboratory testing (Reynolds, 2017). Supplemental vitamin K injection will prevent vitamin K-dependent hemorrhagic disease of the newborn (Chap. 33, p. 626). A single intramuscular dose of vitamin K, 0.5 to 1 mg, is given within 1 hour of birth (American Academy of Pediatrics, 2017b).


Obstentrics_Williams

Obstentrics_Williams. Numerous mass-screening tests are now available for 29 newborn conditions. Shown in Table 32-4, many are mandated by various state laws (American College of Obstetricians and Gynecologists, 2017 c). lost states require that all tests in the core panel be performed. Supplemental conditions-secondary targets-are also listed on the Maternal and Child Health Bureau website. Some states require some of these in addition to their mandated core panel. Each practitioner should be familiar with their individual state requirements, which are available at http:// genes-r-us.uthscsa.edu/resources/consumer/statemap.htm. Newborn gestational age can be estimated very soon after delivery. The relationship between gestational age and birthweight can identiy neonates at risk for complications. For example, (cobalamin A, B) Propionic 3-Ketothiolase aDetermined by tandem mass spectrometry. bAdded after 2006. From Centers for Disease Control and Prevention, 20r12; Watson, 2006.


Obstentrics_Williams

Obstentrics_Williams. From Centers for Disease Control and Prevention, 20r12; Watson, 2006. The Newborn 61 5 neonates who are either small or large for gestational age are at greater risk for hypoglycemia and polycythemia, and measurements of blood glucose and hematocrit are indicated. • Care of Skin and Umbilical Cord All excess vernix, blood, and meconium is gently wiped of after delivery while keeping the newborn warm. Any remaining ver nix is readily absorbed and disappears within 24 hours. he first bath is postponed until the neonate's temperature is stable.


Obstentrics_Williams

Obstentrics_Williams. Aseptic precautions are observed in the immediate care of the cord. The American Academy of Pediatrics has concluded that keeping the cord dry is suicient care (Stewart, 2016). he umbilical cord begins to lose water from Wharton jelly shortly after birth. Within 24 hours, the cord stump loses its characteristic bluish-white, moist appearance and soon becomes dry and black. Within several days to weeks, the stump sloughs and leaves a small, granulating wound, which after healing forms the umbilicus. Separation usually takes place within the irst 2 weeks. The range is 3 to 45 days (Novack, 1988). he umbilical cord dries more quickly and separates more readily when exposed to air. Thus, a dressing is not recommended.


Obstentrics_Williams

Obstentrics_Williams. In resource-poor countries, local antimicrobial prophylaxis is reasonable (Salam, 2014). Triple-dye applied to the cord was reported to be superior to soap and water care in preventing colonization and exudate formation Qanssen, 2003). In a Nepalese study, cleaning the cord stump with 4-percent chlorhexidine reduced severe infection by 75 percent compared with soap and water (Mullany, 2006). Likewise, O.l-percent chlorhexidine powder was superior to dry cord care (Kapellen, 2009). he World Health Organization (2014) recommends cleansing with chlorhexidine.


Obstentrics_Williams

Obstentrics_Williams. Despite precautions, a serious umbilical infection-omphaLitis-sometimes develops. In a German study of more than 750 newborns with aseptic cord care, 1.3 percent sufered such infections (Kapellen, 2009). he most likely ofending organisms are StaphyLococcus aureus, Escherichia coLi, and group B streptococcus. Typical signs of cellulitis and stump discharge usually aid diagnosis. Mild erythema and some bleeding at the stump site with cord detachment is also common, but some cases present with no outward signs.


Obstentrics_Williams

Obstentrics_Williams. In 2016, 81 percent of U.S. newborns were initially breastfed, 52 percent were still breastfed at 6 months, and 31 percent at 1 year (Centers for Disease Control and Prevention, 2016). According to the American College of Obstetricians and Gynecologists (2017 e), exclusive breastfeeding is preferred until 6 months. In many hospitals, breastfeeding begins in the delivery room. Most term newborns thrive best when fed 8 to 12 times daily for approximately 15 minutes each episode. Preterm or growth-restricted newborns require feedings at shorter intervals. Breastfeeding is discussed further in Chapter 36 (p. 656).


Obstentrics_Williams

Obstentrics_Williams. Because most neonates actually receive little nutriment for the first 3 or 4 days of life, they progressively lose weight until the flow of maternal milk is established or other feeding is instituted. Preterm neonates lose relatively more weight and regain their birthweight more slowly. Conversely, growth-restricted but otherwise healthy newborns regain their initial weight more quickly than those born preterm. With proper nourishment, birthweight of term newborns usually is regained by 10 days. For the irst 2 or 3 days after birth, the colon contains sot, brown-green meconium. his consists of desquamated epithelial cells from the intestinal tract, mucus, epidermal cells, and lanugo (fetal hair) that have been swallowed along with amnionic luid. The characteristic color results from bile pigments. During fetal life and for a few hours after birth, the intestinal contents are sterile, but bacteria quickly colonize the bowel contents.


Obstentrics_Williams

Obstentrics_Williams. The characteristic color results from bile pigments. During fetal life and for a few hours after birth, the intestinal contents are sterile, but bacteria quickly colonize the bowel contents. Meconium stooling is seen in 90 percent of newborns within the irst 24 hours, and most of the rest within 36 hours. Usually, newborns irst void shortly ater birth but may not until the second day. Meconium and urine passage indicates patency of the gastro intestinal and urinary tracts, respectively. Failure of the newborn to stool or urinate ater these times suggests a congenital defect, such as Hirschsprung disease, imperforate anus, or posterior urethral valve. Ater the third or fourth day, as a result of milk ingestion, meconium is replaced by light-yellow, soter, homogenous feces.


Obstentrics_Williams

Obstentrics_Williams. Between the second and fifth day of life approximately one third of all neonates develop physiological jaundice of the newborn. It has special significance considering most hospitals have policies for early discharge. Guidelines regarding standard phototherapy equipment and monitoring, as well as treatment recommendations per gestational age, hour of life, and risk factors are used (Bhutani, 2011; Maisels, 2009). Hyperbilirubinemia is discussed further in Chapter 33 (p. 626).


Obstentrics_Williams

Obstentrics_Williams. Neonatal circumcision of male infants has been a controversial topic in the United States for at least 30 years. Even so, scientific evidence supports several medical beneits that include prevention of phimosis, paraphimosis, and balanoposthitis. Circumcision also lowers the incidence of penile cancer and of cervical cancer among their sexual partners. Previously, the American Academy of Pediatrics Task Force on Circumcision (1999) concluded that existing evidence was insuicient to recommend routine neonatal circumcision. It seems that this policy has had only a negligible efect on practices in this country. Speciically, the Centers for Disease Control and Prevention (2011) estimated that the newborn male circumcision rate declined during a 12-year period from approximately 60 percent in 1999 to only 55 percent in 2010. Other studies have endorsed health beneits of circumcision.


Obstentrics_Williams

Obstentrics_Williams. Other studies have endorsed health beneits of circumcision. In large randomized trials from regions of Africa with a high prevalence of human immunodeiciency virus (HIV), male circumcision was found to lower the risk of HIV acquisition in the adult by half (Bailey, 2007; Gray, 2007). And, male circumcision was also reported to decrease adult incidences of HIV, HPV, and herpes infections (Tobian, 2009). In its subsequent policy statement, the American Academy of Pediatrics Task Force on Circumcision (2012) concluded that health beneits of newborn male circumcision outweigh the risks. hus, access to the procedure is justified for families who choose it. The Task Force stopped short of recommending circumcision for all newborns. Circumcision is performed only in a healthy neonate. Other contraindications include any genital abnormalities such as hypospadias and a family history of a bleeding disorder, unless excluded in the newborn.


Obstentrics_Williams

Obstentrics_Williams. The Task Force (2012) recommends procedural analgesia. Various pain relief techniques include lidocaine-prilocaine topical cream, local analgesia iniltration, dorsal penile nerve block, or ring block (Arnett, 1990; Stang, 1988). The dorsal penile nerve block or the ring block is superior to topical analgesia (Hardwick-Smith, 1998; Lander, 1997; Taddio, 1997). he use of a paciier dipped in sucrose is a useful adjunct to these methods (Kaufman, 2002). After appropriate penile cleansing, the ring block places a wheal of I-percent lidocaine at the base of the penis and then advances the needle in a 180-degree arc around the base of the penis. The needle is advanced first to one side and then to the other to achieve a circumferential ring of analgesia. he maximum dose of lidocaine is 1.0 mL. No vasoactive compounds such as epinephrine should ever be added to a local analgesic agent or circumcision.


Obstentrics_Williams

Obstentrics_Williams. The most commonly used instruments are shown in Figure 32-5 and are Gomco and Mogen clamps and the Plastibell device. Compared with the Gomco procedure, Kaufman and colleagues (2002) reported that the Mogen technique required FIGURE 32-5 Three different tools used for circumcision. A.Mogen clamp. The arms of the clamp open to a 3-mm maximum width. B. Gomco clamp, assembled. C. Plastibell device.


Obstentrics_Williams

Obstentrics_Williams. FIGURE 32-5 Three different tools used for circumcision. A.Mogen clamp. The arms of the clamp open to a 3-mm maximum width. B. Gomco clamp, assembled. C. Plastibell device. less time to perform and was associated with less apparent discomfort for the newborn. Regardless of the method used, the goal is to remove enough shaft skin and inner preputial epithelium so that the glans is exposed suiciently to prevent phimosis. In all techniques: (1) the amount of external skin to be removed must be accurately estimated, (2) the preputial oriice must be dilated to visualize the glans and ensure that it is normal, (3) the inner preputial epithelium must be freed from the glans epithelium, and (4) the circumcision device must be left in place long enough to produce hemostasis before amputating the prepuce (Lerman, 2001).


Obstentrics_Williams

Obstentrics_Williams. The risks for bleeding, infection, and hematoma formation are low (Christakis, 2000). Unusual complications include distal glans amputation, acquisition of HIV infection or other sexually transmitted disease, meatal stenosis, penile denudation, penile destruction with electrosurgical coagulation, subsequent epidermal inclusion cyst and urethrocutaneous fistula, and ischemia following the inappropriate use of lidocaine with epinephrine (Amukele, 2003; Neulander, 1996; Nicoll, 1997; Pippi-Salle, 2013; Upadhyay, 1998). Hospital rooming in places newborns in their mothers' rooms instead of central nurseries. This practice attempts to make all phases of childbearing as natural as possible and to foster early mother-child relationships. By 24 hours, the mother is generally fully ambulatory. hereafter, with rooming-in, she can usually provide routine care for herself and her newborn. n obvious advantage of this is her ability to assume full care when she arrives home.


Obstentrics_Williams

Obstentrics_Williams. Traditionally, the newborn is discharged with its mother, and in most cases, maternal stay has determined that of the neonate. From 1970 to the mid-1990s, average maternal postpartum length of stay declined steadily, and many mothers were discharged before 48 hours. The World Health Organization (2014) cites a minimal stay of only 24 hours. Although it is clear that most newborns can be safely discharged within 48 hours, this is not uniformly true. For example, in more than 2.1 million neonates in Canada, Liu and associates (2000) examined readmission rates following initial neonatal discharge. As the length of hospital stay dropped from 4.2 days in 1990 to 2.7 days in 1997, the readmission rate rose from 27 to 38 per 1000. Dehydration and jaundice accounted for most of these readmissions. Using Washington state data, Malkin and coworkers (2000) found that the 28-day mortality rate was increased fourfold in newborns discharged within 30 hours of birth, and the I-year mortality rate


Obstentrics_Williams

Obstentrics_Williams. Using Washington state data, Malkin and coworkers (2000) found that the 28-day mortality rate was increased fourfold in newborns discharged within 30 hours of birth, and the I-year mortality rate grew twofold. Safe discharge for latepreterm newborns has special concerns (Whyte, 2012).


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Obstentrics_Williams. Because of the increased scrutiny regarding short hospital stays, federal legislation-he Newbons' and Mothers' Health Protection Act of 199-was enacted to prohibit insurers from restricting hospital stays for mothers and newborns to less than 2 days for vaginal delivery or 4 days for cesarean delivery. In an analysis of more than 662,000 births in California, Datar and Sood (2006) found that readmission rates declined by 9, 12, and 20 percent, respectively, at 1, 2, and 3 years after the legislation was implemented. li A, Khadije D, Elahe A, et al: Prophylaxis of ophthalmia neonatorum comparison of Betadine, erythromycin and no prophylaxis. J Trop Pediatr 53(6):388, 2007 American Academy of Pediatrics: Delayed umbilical cord clamping after birth. Pediatrics 139(6), 2017a American Academy of Pediatrics, American College of Obstetricians and Gynecologists: Care of the newborn. In Guidelines for Perinatal Care, 8th ed. Elk Grove Village, AAP, 2017b


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Obstentrics_Williams. American Academy of Pediatrics, American College of Obstetricians and Gynecologists: Care of the newborn. In Guidelines for Perinatal Care, 8th ed. Elk Grove Village, AAP, 2017b American Academy of Pediatrics Task Force on Circumcision: Circumcision policy statement. Pediatrics 103:686, 1999 American Academy of Pediatrics Task Force on CircumCIsIOn: CircumCIsion policy statement. Pediatrics 130(3):585,t2012 American College of Obstetricians and Gynecologists: Executive summary: neonatal encephalopathy and neurologic outcome, second edition. Report of the American College of Obstetricians and Gynecologists' Task Force on Neonatal Encephalopathy. Obstet Gynecol 123(4):896,t2014 American College of Obstetricans and Gynecologists: Delayed umbilical cord clamping after birth. Committee Opinion No. 684, January 2017a American College of Obstetricians and Gynecologists: Delivery of a newbor� with meconium-stained amniotic fluid. Committee Opinion No. 689, Apnl 2017b


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Obstentrics_Williams. American College of Obstetricians and Gynecologists: Delivery of a newbor� with meconium-stained amniotic fluid. Committee Opinion No. 689, Apnl 2017b American College of Obstetricians and Gynecologists: Newborn screening and the role of the obstetrician-gynecologist. Committee Opinion No. 616, January 2015, Reairmed 2017c American College of Obstetricians and Gynecologists: Planned home birth. Committee Opinion No. 697, Aprilt2017d American College of Obstetricians and Gynecologists: Optimizing support for breastfeeding as part of obstetric practice. Committee Opinion No. 658, February 2016, Reairmed 2017 e American College of Obstetricians and Gynecologists. American Academy of Pediatrics: The Apgar score. Committee Opinion No. 644, October 2015, Reairmed 2017f Amukele SA, Lee GW, Stock JA, et al: 20-year experience with iatrogenic penile injury. J Urolt170:1691, 2003 . Apgar V: A proposal for a new method of evaluation of the newborn mfant.


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Obstentrics_Williams. Amukele SA, Lee GW, Stock JA, et al: 20-year experience with iatrogenic penile injury. J Urolt170:1691, 2003 . Apgar V: A proposal for a new method of evaluation of the newborn mfant. Curr Res Anesth Analg 32:260, 1953 Armstrong L, Stenson BJ: Use of umbilical cord blood gas analysis in the assessment of the newborn. Arch Dis Child Fetal Neonatal Ed 92:430, 2007 Arnett M, Jones JS, Horger EO III: Efectiveness of 1% lidocaine dorsal penile nerve block in infant circumcision. Am J Obstet Gynecol 163:1074, 1990 Bailey RC, Moses S, Parker CB, et al: Male circumcision for HIV prevention in young men in Kismu, Kenya: a randomized controlled trial. Lancet 369:643, 2007 Bhatt S, Alison BJ, Wallace EM, et al: Delaying cord clamping until ventilation onset improves cardiovascular function at birth in preterm lambs. J Physiol 591(8):2113,t2013


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Obstentrics_Williams. Bhatt S, Alison BJ, Wallace EM, et al: Delaying cord clamping until ventilation onset improves cardiovascular function at birth in preterm lambs. J Physiol 591(8):2113,t2013 Bhutani K,Committee on Fetus and Newborn, American Academy ofPediatrics: Phototherapy to prevent severe neonatal hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics 128(4):el046, 2011 Blickstein 1, Green T: Umbilical cord blood gases. Clin Perinatol 34(3):451, 2007 Carrasco M, Martell M, Estol PC: Oronasopharyngeal suction at birth: efects on arterial oxygen saturation. J Pediatr 130(5):832, 1997 . Casey BM, Goldaber KG, Mcintire DD, et al: Outcomes among term mfants when two-hour postnatal pH is compared with pH at delivery. Am J Obstet Gynecol 184:447, 2001a Casey BM, Mcintire DD, Leveno KJ: he continuing value of the Apgar score for the assessment of newborn infants. N Engl J Med 344:467, 2001b


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Obstentrics_Williams. Casey BM, Mcintire DD, Leveno KJ: he continuing value of the Apgar score for the assessment of newborn infants. N Engl J Med 344:467, 2001b Centers for Disease Control and Prevention: Breastfeeding report card: progressing toward national breastfeeding goals-United States 2016. Available at: http://www.cdc.gov/breastfeeding/data/reportcard2.htm. Accessed June 2017 Centers for Disease Control and Prevention: CDC grand rounds: newborn screening and improved outcomes. MMWR 61(21)390,t2012 Centers for Disease Control and Prevention: Trends in in-hospital newborn male circumcision-United States, 1999-2010. MMWR 60(34):1167, 2011 Chauhan SP, Cowan BD, Meydrech EF, et al: Determination of fetal acidemia at birth from a remote umbilical arterial blood gas analysis. Am J Obstet Gynecol 170: 1705, 1994 Christakis DA, Harvey E, Zerr DM, et al: A trade-of analysis of routine newborn circumcision. Pediatrics 105:246,t2000


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