Chapters Transcript Delayed Fetal Pillow Welcome and thank you for attending this event is brought to you by cooper surgical, a leading provider of medical devices for women's health care. For 31 years, cooper surgical has worked with health care providers to provide highly effective clinic and practice based contraceptive, surgical and obstetric solutions to complement our portfolio of trusted and reliable medical devices. We have also broadened our offerings, investing in the areas of reproductive genomics and in vitro fertilization. We are fully committed to helping improve the delivery of health care to women and their families, cooper surgical manufacturers over 600 clinically relevant medical devices used by healthcare providers and offices, clinics, operating rooms, labor and delivery suites and reproductive IVF clinics worldwide. Clinicians overwhelmingly say they trust our products for their reliability, innovation and efficiency. We are pleased to provide this educational opportunity on behalf of cooper surgical. Welcome and thank you for participating in tonight's event. My name is Jim Young product director for cooper surgical and I will be coordinating tonight's program. Tonight's presentation is entitled fetal pillow for full dilation, cesarean section. We will have approximately 30 minutes for the presentation. The presenter will then participate in a question and answer session upon conclusion of the presentation. If your question is not answered this evening, you will receive a response from cooper surgical After tonight's event. To submit a question. Please click the ask a question button located under this player window and complete the form. Also after the Q. And A. Please spend a few moments completing a brief survey about tonight's program. I'm very pleased to introduce our presenter, Dr Daniel Swarovski, Professor of obstetrics and gynecology, weill Cornell medicine and chief of obstetrics and gynecology at new york presbyterian Queens Hospital. Good evening Dr scott Ski thank you Jim thank you for having me tonight and for everyone it's my pleasure to be here and to talk with you about a safe alec elevation device. The fetal pillow. Our agenda tonight is to go through a case presentation, discuss pelvic anatomy as it relates to second stage cesarean delivery. Talk about the morbidity of second stage cesareans. Look at the evidence that the fetal pillow may help to decrease that morbidity. Go through the fetal pillow design and use and lastly talk about how we implemented it here at my place, new york presbyterian queens or N. Y. P. Q. The case presentation is one that all obstetricians have probably had the fortunate or unfortunate circumstance to take care of. And that is a 32 year old gravity one pair of zero. At 39 weeks of gestation with no medical conditions and a normally grown fetus on her last ultrasound which was done at 33 weeks of gestation for size. Deep discrepancy who presents to labor in spontaneous labor. She's been in labor for 28 hours and there's been slow progress in dilation. Four hours ago she became fully dilated. Had a pretty good epidural in so had not much of an urge to push. So she labored down for an hour and has been pushing for three hours. Now, She's at plus two station and her pushing is only moderately effective because she's becoming exhausted. Your assessment is that the vacuum was probably not likely to be successful. And you want to perform a cesarean delivery during the cesarean. The head is deeply engaged, not a surprise. And you ask for a vaginal hand to elevate the head. So I have a series of questions. And the first question is, who performs the vaginal hand head elevation? Sometimes it's someone with a fair amount of experience, but often it's the one with the least experience because the important people are scrubbed in or running around the operating room, getting things that are necessary? And often it's someone with very little experience. And if it's really difficult, that might mean an increase in morbidity when someone needs to press really hard. The next question is, what are the complications maternal and fetal of second stage cesarean delivery? I'll go through those a few slides from now. The third question is, how often does a busy obstetrician do a cesarean delivery in the second stage? The very next slide, I'll show you that and talk about why that's important. The next question is, what are the risk factors for uterine incision lacerations or extensions? There are probably only a couple. One would be if it's a repeat cesarean with a lot of adhesions. That's not our case today, but the other is simply second stage cesarean with the head deeply engaged in the pelvis. That makes it difficult and raises the risk for extensions. In addition, where you place the uterine incision is also important because if you go too low and you're actually going through cervix or vagina, that raises the risk of extensions, the next question is, what are the contraindications to fetal pillow placement? And that is if the cervix is not fully dilated because it has not been tested in that circumstance, we don't have any experience and if we want to first do no harm, we would have to study that before introducing it clinically. And so not only is that the case, but also it's not likely to be necessary when the cervix is not fully dilated because the fetal head won't be deep in the pelvis. Lastly I want to get to your questions but we'll do that in a question and answer session as soon as we're done here, A busy obstetrician delivers somewhere between 150 deliveries per year. Really busy obstetricians, maybe someone, But if you take the somewhat average Cesarean rate 35 or 40% for our country and I'm gonna choose 40% because it makes the math easier. Second stage Cesarean is roughly 10% of all Cesarean deliveries, that works out to about 4% of all deliveries And with 100 or 150 deliveries per year. The average obstetrician would do a second stage cesarean maybe four, maybe six times per year. And if you're less busy less often. And so this is not enough to get really good at doing this, especially when the head is deep in the pelvis. Only doing this a few times a year means it's a setup for morbidity for those women. This side shows a mock up of the pelvis from the front and what I want to point out here is two things. The first is the pelvic inlet. You can see the sacral promontory that's labeled toward the top of the image and at the bottom ish is the pubic synthesis which you see labeled at the bottom and a little little off to the left. If you draw a line around the iliac bone going either way from sacred promontory to the synthesis pubis, that is the pelvic inlet. You can also see in this image, the issue spines. One of them is labeled way off to the left and they are somewhat deep in the pelvis which you can't really appreciate in this image. As you can see here. This is a an oblique view of the pelvis. Similarly, you see the synthesis pubis toward the bottom and a little towards the right and the sacred promontory near the top in the center. If you draw a line and you can see a line almost drawn by itself along the iliac bone in the far bone away from us from the sacred promontory to the synthesis, it's kind of white for the first half and then a little dark for the second half. You can't see it on the nearer iliac bone because of the oblique view. But that is the pelvic inlet. If you draw a circle around from sacred promontory to synthesis pubis and then back up the other side, the issue of spines which I mentioned on the previous slide, you can also see in this slide but they are dark. One of them from the far iliac bone is just above the synthesis pubis. And one of them is a little point that you can see through the operator framing of the nearly a backbone. Those issues spines. You can see better in this image how far away or deep they are inferior to the pelvic inlet. That line that we drew around from psycho promontory to synthesis pubis. When the fetal head is deep in the pelvis, those when the bip Rydell diameter is at the issue of spines that is zero station and we're at plus two station. So it's even deeper than that. And so you can tell even if you're not an obstetrician that if you're going right above this emphasis pubis and trying to get to a head that's very deep, deeper than the issue of spines. It may be difficult. This is a mock up of the fetus during late pregnancy for a woman who's not labor. What I want to point out here is the relationship of the fetal head to the pelvis. The line that says umbilical cord, that black line toward the right, just below. That is where the sacred promontory is on the spine below that and to the left, you can see where pubic synthesis is labeled. And if you draw a line from the sacral promontory to the pubic synthesis, most of the head is above or to the left from that, this is a fetus before it enters labor. Notice the fetus is nearly always in the flexed position and even if it's not, it will become so as it descends into the pelvis and that's because the longest diameter of the fetal head, which is mentum to oxy put can't fit through the pelvis so it has to go down the long axis of the pelvis. And it can only do that with the fetal head flexed and and that's because the head compared to the pelvis is almost as big. All the tissues need to be compressed in order for the fetal head to get down and through the birth canal. And what that means is when it's deeply engaged in the pelvis during the second stage and you do a cesarean and try to come in from above to elevate the head. There's not enough room for your fingers to get around the head to bring it up. In addition, when we do a vaginal hand and which is generally done with two fingers in the vagina because more don't fit two fingers pressing on one of the fetal skull bones has a surface area of maybe two centimeters maybe less. And so all the force that needs to be applied to raise the fetal head is applied to two cm on the skull and if it's done with enough force it can create injury. The fetal pillow, however, Has an area that is 10 cm, maybe more. And so it can apply the same force broadly across a much bigger area and the risk of injury is much less. The fetal morbidity from second stage cesarean delivery includes what you see here, skull fractures, subdural hemorrhage, septal hematoma and scalp lacerations and the maternal morbidity is what you see here, cervical vaginal and broad ligament lacerations that lead to massive blood loss that lead to blood transfusion, massive blood loss can lead to kogelo path E and all of this may lead to an icu admission. What I want to show you now is the evidence that the fetal pillow can limit or decrease this kind of morbidity for both mom and baby and to do that. I'm going to go to what we know our level one evidence randomized controlled trials. The first one is from dr seal and colleagues, which was a randomized controlled trial in the International Journal in 2016. They had 120 patients in each group randomized to get fetal pillow or not get. And as I highlighted for you here, uterine extensions were markedly decreased from 36% to 10% in the Fetal Pillow group. And this was significant. The next Article is from Lassie and colleagues in the Green Journal in 2020, also a randomized control trial and showed similarly as you see in the highlight here, A decrease from 43% in the group who did not get inflated to the 20-20% in the group who were inflated. And there were 30 patients in each group, not as many, but still almost significant With the p of .05. This is the fetal pillow. It is an inflatable balloon as you can see on the left with a semi rigid platform that houses that balloon with a tube that allows us access to inflate. And the picture on the right shows a little mock up of what it sort of looks like if you if you could see through tissues when it's in. So it's in the vagina which is an opening that you can't see in this picture, but it's toward the left there and it's under the fetal head. And when we inflate it, it helps to gently elevate the fetal head and we're going to go now to a short video that demonstrates kind of in real time how to use it, how to place it and the effect of when you have the inflation done that, you can actually see the elevation. Cooper surgical is proud to introduce fetal pillow, fetal pillow is intended to elevate the fetal head and facilitate the delivery of the fetus. In women requiring a cesarean section at full dilation, or those requiring a cesarean section after a failed instrumental vaginal delivery Fetal Pillow is indicated for use and gestational age greater than 37 weeks insertion and inflation of the device should be carried out just before performing the cesarean section, insert the device using a sterile lubricating cream or gel. The processes like inserting a soft vacuum cup. Hold the base plate of the fetal pillow between the fingers and thumb and fold to squeeze the dome of the balloon between the base plate. The tube attachment should be at the superior end during insertion. Make sure that the dome of the balloon surface is in contact with the fetal head and the base plate in contact with the pelvic floor. Once inserted, the device should be pushed posterior lee until it is touching the coccyx. The position is like the insertion of a vacuum cup for an occipital posterior position. The patient's legs must be placed flat before inflation is carried out using sterile saline with the 60 CC Syringe provided if the legs are not placed flat before inserting the device can be expelled or could move during inflation and fail to produce the desired elevation. A total of 180 CCs of sterile saline three syringes of fluid is required to produce the desired elevation. Close the lower valve after filling to prevent the fluid from leaking inflation volume should not exceed 180cc After delivery of the baby. The two way valve is open to release the fluid. The devices were moved at the end of the procedure by pulling on the tubing or hooking a finger on the plate and pulling the device out of the vagina. So that animation gave you a really great idea of how to use in place the fetal pillar. And what happens when you do inflate it. Now I'd like to talk about implementation and maybe you think well if I know how to use it, what do you mean implementation? I think it's actually really important that all the other team members are on board and know how to use this device for a couple different reasons. One is busy. Obstetricians are often called for emergencies and if you're in the middle of doing something and you need to zip for an emergency, someone else can can complete the process of inflating the fetal pillow. But equally important if everyone knows about it, we remember someone will remember because and allow us to put the device into play more frequently. We're in a situation right now where we're trying to change the culture or change the practice and it's not so easy simply because they're used to doing it a certain way everyone is and we don't remember we're having this problem even at my place. And so what I wanna do is emphasized that an organized education program for everyone is what will get you there. And we do this with a trainer that cooper company has developed for the fetal pillow that you see in the picture here. This shows the trainer and how you have to fold the device in half when it is not inflated right here. Place it in with the tube facing up and that's important because it allows the inflation to happen without qingqing the tube and pushing it posterior early. So it is directly under the fetal head. It's important that the patient's legs are then placed flat before inflating it so that it won't get expelled during the inflation. And as the inflation is occurring you can see the fetal head and fetus being raised which is happening right here. We're using air in this training session just so water doesn't get all over the place but never use air in an actual patient always saline or sterile water. And the total is 180 CCS. So that video gave you a great idea of how we use that trainer in our implementation and education. We also use skills days and this is our announcement for our most recent quarterly skills day that we have on labor and delivery. We go through and everyone gets practice at quantitative blood loss, the jade a device for postpartum hemorrhage the Belmont rapid infuser when there's massive hemorrhage. We want to transfuse rapidly and the fetal pillow. In addition to some surgical techniques that we have a mannequin, we can practice on like the b lynch suture and uterine artery ligation. So this type of day we set up so that everyone gets practice. Uh residents, physician assistants, midwives, all the nurses and the attending physicians. And everyone loves these kinds of days because they know the trouble they get into every once in a while. They want to prevent it and they want to know how to use the device of the fetal pillow. So we get great attendance. And this is a great way to organize the education and be able to implement fetal pillow into your labor and delivery unit so that everyone knows about and when everyone knows about it knows how to use it. You develop some excitement on the unit about how you are improving outcomes for women. And it helps everyone if the doctor doesn't remember it, maybe the nurse will or the midwife will or the physician assistant will or the resident will. And if someone suggests it then we use it more often. Now you might say I'm a really great surgeon. I'm a really great obstetrician. I don't need this fetal pillow. I have meticulous surgical technique. Even if those elaborate lacerations happen and they won't very often because I do such a good job, I can sew them up and I don't need it. But if you said that you'd be forgetting a couple of things first, even though it may be unusual, it does happen that you so everything up, it looks as dry as a bone. You close the patient up and within a few hours, maybe 12 hours later, one of those blood vessels that retracted into the tissue and wasn't bleeding when you sewed everything up was missed by the sutures and begins to bleed again, giving you hematomas or him a peritoneum and then you have to go back to the operating room to try to stop that. You won't be able to eliminate that. And using the fetal pillow will help you eliminate the times when there are extensions of the laceration and decrease the morbidity. The second thing you'd be forgetting is fetal pillow is a preventive method. An ounce of prevention is worth a pound of cure as Benjamin franklin said hundreds of years ago in poor Richard's almanac and I would advocate that this is better. So I think we can reduce maternal and fetal morbidity that occurs during cesarean delivery. That is happening during the second stage of labor for women when we use the fetal pillow and I think this needs to be increased and nearly routine usage so we can improve these outcomes. Thank you Created by
