Download Obstetrical Emergencies

Obstetrics
Knowing How to Catch
Pregnancies
•Most are uncomplicated
•Complications can arise from:
–Eclampsia/Pre-eclampsia
–Diabetes
–Hypotension/Hypertension
–Cardiac disorders
–Abortion
–Trauma
–Placenta abnormalities
Childbirth
•Involves Labor and Delivery
•Natural process, often only requiring basic assistance
Childbirth
•You have at least two patients!
Childbirth
•Complications can occur
–Breech/limb presentation
–Multiple Births
–Umbilical cord problems
–Disproportion
–Excessive bleeding
–Pulmonary embolism
–Neonate requiring resuscitation
–Preterm labor
Anatomy/Physiology
•Ovulation
•Fertilization
•Implantation
Anatomy/Physiology
•Placenta
–Transfer of gases
–Transport of nutrients
–Excretion of wastes
–Hormone production
–Protection
Anatomy/Physiology
•Umbilical cord
–Connects placenta to fetus
–Two arteries
–One vein
•Amniotic Sac
–Membrane surrounding fetus
–Fluid originates from feral sources
–500 - 1000 cc (after 20 weeks)
–Rupture produces watery discharge
Terminology
•Antepartum - before delivery
•Postpartum - after delivery
•Prenatal - occurring before the birth
•Natal - connected with birth
•Gravida - number of pregnancies
•Para - number of pregnancies carried to full term
Terminology
•Abortion - number of pregnancies that ended before full term
•Primigravida - woman who is pregnant for the first time
•Primipara - woman who has given birth to her first child
•Multiparous - woman who has given birth multiple times
•Gestation - period of time for intrauterine fetal development
Terminology
•When giving pregnancy information it is listed / documented as:
–G - #, P - #
–Example:
•G3, P1 = Mom has been prgenant 3 times with 1 live birth
(She may be currently carrying one)
•G2, P3 = How does that happen?
•Gestation is 10 lunar months or 40 weeks
–Approximately 9 calendar months
Fetal Growth Process
•End of third month - 12 weeks
–Sex may be distinguished
–Heart is beating
–Every structure found at birth is present
•End of fifth month - 20 weeks
–Fetal heart tones can be detected
–Fetal movement may be felt by mother
•End of sixth month - 24 weeks
–May be capable to survive if born prematurely
•Middle of tenth month - 37 weeks
–Considered to have reached full term
–Expected date of confinement (EDC)
Ectopic Pregnancy
•Pathophysiology
–Outside uterine cavity
•95% Fallopian tubes
–1 in every 200 pregnancies
–Most are symptomatic
–Predisposing factors
•Tubal infections
•Previous tubal surgery
•IUD use
•previous ectopic pregnancy
Ectopic Pregnancy
•History
–Missed period
–Other signs of early pregnancy
–Vaginal bleeding 6 -8 weeks after last period
•Upon rupture, bleeding may be excessive
Ectopic Pregnancy
•History
–Lower abdominal pain
•May be:
–Sharp or dull
–Constant or intermittent
–Diffuse or localized
•May be referred to shoulder
Ectopic Pregnancy
•Physical Exam
–S/S of hypovolemic shock
–Positive tilt test
–Tender lower abdomen
–Palpable mass may be present
Ectopic Pregnancy
Abdominal pain or unexplained hypovolemia + woman of child-bearing
age = Ectopic pregnancy until proven otherwise!
Ectopic Pregnancy
•Management
–High concentration oxygen
–IV or IV’s with LR
–MAST
–Immediate transport
Abortion
•Termination of pregnancy before fetal viability (20th week)
Abortion
•Induced
–Therapeutic
–Criminal
–Elective
Abortion
•Spontaneous
–20 -25% of pregnancies terminate spontaneously
–Usually due to embryo abnormalities
–May also result from infection, unfavorable intrauterine
environment, cervical incompetence
Abortion
•Spontaneous
–Threatened
–Inevitable
–Complete
–Incomplete
Abortion
•Threatened
–Vaginal bleeding, mild or absent contractions, closed cervix
•20% of women bleed in early pregnancy
•50% go on to abort
–Any bleeding in early pregnancy is dangerous and abnormal
Abortion
•Inevitable
–Vaginal bleeding
–Moderately severe contractions
–Possible amniotic sac rupture
–Cervix effacement and dilation
–Changes are irreversible
Abortion
•Completed
–Products of conception expelled
•fetus
•placenta
•decidual lining
–Signs, symptoms
•Profuse vaginal bleeding
•Passage of tissue, clots
•Continuing mild contractions
•Possible hypotension
Abortion
•Incomplete
–Products of conception retained
–Signs, symptoms
•Profuse bleeding
•Passage of tissue/clots
•Severe contractions
•Hypotension, shock
•Sepsis
Abortion
•Missed
–Fetus dies in utero before 20th week
–Retained at least 2 months afterwards
Abortion
•Missed
–Signs/Symptoms
•Continued amenorrhea
•History of bleeding without cramping
•Decrease in uterine size
–Resorption of fluid
–Calcification of products of conception
Abortion
•History
–Confirmed or suspected pregnancy
–Abdominal pain, cramping
–Bleeding, passage of tissue
Abortion
•Physical Exam
–Orthostatic vital signs (tilt test)
–Examine for amount of vaginal bleeding, presence of tissue
Abortion
•Management
–High concentration oxygen
–IV or IV’s with LR
–MAST if indicated
–Do NOT pack vagina
–Save any tissue passed
–Transport
Medical Complications
•Diabetes
–Stable may become unstable
–Gestational
–Can not use oral medications
•Neuromuscular
–May be aggravated by pregnancy
Medical Complications
•Hypertension
–More susceptible to complications
•CVA
•Cardiac Failure
•Renal Failure
–May be complicated by preeclampsia or eclampsia
•Cardiac Disorders
–Additional stress placed on heart
–CO increases 30% by week 34
Pregnancy-Induced Hypertension
•Frequently referred to as PIH
•Two Phases:
–Pre-eclampsia
–Eclampsia
Pre-Eclampsia
•In about 7% of pregnancies
•Between 20th week gestation, first week postpartum
•Hypertension, albuminuria, edema
Pre-Eclampsia
•Risk Factors
–First pregnancies
–Multiple gestations
–excessive amniotic fluid
–Diabetes mellitus
–Renal disease
–Pre-existing hypertension
–Family history of pre-eclampsia
–Poor nutrition
Pre-Eclampsia
•Signs/Symptoms
–Elevated BP
•>140/90 or >30mmHg above patient normal
–Edema of face/hands
•Especially in morning
Pre-Eclampsia
•Signs/Symptoms
–Rapid weight gain
•>3lb/wk - 2nd trimester
•>1lb/wk - 3rd trimester
–Decreased urine output
Pre-Eclampsia
•Signs/Symptoms
–Severe headache
–Blurred vision
–Irritability
–Nausea, vomiting
–Epigastric pain
–Pulmonary edema
Eclampsia
•Pre-eclampsia + Seizures, Coma
PIH
•Management
–High concentration oxygen
–IV tko
–Left lateral recumbent position
–Quiet environment
–Reduce excessive light
PIH
•Psychological support
•Avoid lights/sirens in pre-eclampsia
•Magnesium sulfate
–4gm bolus; 1gm/hr infusion
–Monitor pulse, BP, respiration, patellar reflex
–Calcium will reverse toxicity
PIH
•Assess every pregnant patient for:
–Increased BP
–Edema
•Take all reported seizures in pregnant females seriously
H.E.L.L.P. Syndrome
•Complication of severe pre-eclampsia
•Hemolysis
•Elevated
•Liver enzymes
•Low
•Platelets
H.E.L.L.P. Syndrome
•Etiology
–Due to damaged liver endothelial cells
–Platelet aggregation
–Adherence/fibrin deposits
–Elevated liver enzymes
–PT prolonged
–Hepatic vessel rupture
–Hepatic rupture
H.E.L.L.P. Syndrome
•Signs/symptoms
–RUQ/epigastric pain
–N/V
–HA
–DBP greater than 110
–Proteinuria
–Edema
H.E.L.L.P. Syndrome
•Complications
–DIC
–Intercerebral hemorrhage
–Acute renal failure
–CHF
–ARDS
–Death
–Need surgical intervention rapidly
Third Trimester Bleeding
•50% due to normal changes in cervix
•50% due to placental catastrophe
•Dangerous if amount greater than normal period
Abruptio Placentae
•Premature placental separation from uterus
•0.4 - 3.5% of pregnancies
•Risk Factors
–Older patients
–Hypertensives
–Multigravidas
–Trauma
Abruptio Placentae
•Mild to moderate vaginal bleeding
•Continuous, knife-like abdominal pain
•Third trimester pain = Abruption until proven otherwise
•Rigid tender uterus
•S/S of hypovolemia
•Out of proportion to visible bleeding
•Alteration of contraction pattern
Placenta Previa
•Placental implantation over cervical opening
•0.5% of pregnancies
•Predisposing factors
–increasing age
–multiparity
–previous cesarean sections
•Can lead to
–placental insufficiency
–fetal hypoxia
Placenta Previa
•Painless, bright-red vaginal bleeding
•Soft, non-tender uterus
•No contractions
•S/S of hypovolemia
Third Trimester Bleeding
•Management
–100% Oxygen
–IV of LR x 2
–Left lateral recumbent position
–MAST, legs only
–Assess fetal heart tones?
Third Trimester Bleeding
Never perform vaginal exam on third trimester patient with vaginal
bleeding
Hyperemesis Gravidarum
•Severe nausea, vomiting
•Leads to starvation, dehydration, acidosis
•Continued vomiting in pregnancy with loss of weight
Hyperemesis Gravidarum
•Management
–Replace lost fluids, electrolytes
–Glucose
–Consider anti-emetics
Supine Hypotensive Syndrome
•Uterus compresses inferior vena cava
•Venous return to heart decreases
•Decreased venous return leads to decreased cardiac output
•BP decreases
•Consider volume depletion
Supine Hypotensive Syndrome
•Management
–Place patient on left side to restore venous return
–Transport all non-laboring patients in late pregnancy on left side
Premature Rupture of Membranes (PROM)
•Vaginal leakage of clear, colorless fluid
•84% labor spontaneously in 24 hours, BUT
•50% become infected in 12 hours
•Increased time = Increased infection risk
•Patient MUST come to hospital
Fever/Dysuria
•Major medical emergency
•Suggests urinary tract or amniotic fluid infection
•Sepsis or early labor may result
•Patient MUST come to hospital
Uterine Rupture
•Common causes:
–Prolonged labor against obstruction
–Large fetus
–Old C-section
–Multiple pregnancies
Uterine Rupture
•Signs/Symptoms
–Sudden, intense, tearing abdominal pain
–S/S of hypovolemic shock
–Loss of continuity of uterine mass
–Possible vaginal bleeding
Uterine Rupture
•50 - 75% fetal mortality
•Management
–100% Oxygen
–IV of LR x 2
–Left lateral recumbent position
–MAST, legs only
–Rapid transport
Uterine Rupture
•History of previous C-section
–Transport immediately unless baby is crowning
–Determine reason for C-section
Trauma in Pregnancy
•Minor Trauma
–Common in the Obstetric Patient
•Syncopal episodes
•Diminished coordination
•Loosening of the joints
Trauma in Pregnancy
•Major Trauma
–Susceptible to a life threatening episode
•increased vascularity
•may deteriorate suddenly
•Leading cause of maternal death in pregnancy
•MVC’s = 50% of perinatal mortality
Trauma in Pregnancy
•Trauma can lead to
–Premature separation of the placenta
–Premature labor
–Abortion
–Rupture of the uterus
–Fetal death
•Death of mother
•Separation of the placenta
•Maternal shock
•Uterine rupture
•Fetal head injury
Trauma in Pregnancy
•Injured woman of child-bearing age, consider pregnancy
•Priorities EXACTLY same as in any other patient
•ABC’s first
Trauma in Pregnancy
•Assessment
–Vital signs mimic hypovolemia
•Pulse increases 10-15/minute
•BP decreases
Trauma in Pregnancy
•Assessment
–Blood volume increases up to 45%
–More blood loss can occur before S/S of hypovolemia appear
–In hypovolemia, blood is shunted from placenta causing fetal
distress
Trauma in Pregnancy
•Assessment
–Increased fluid volume needed to treat hypovolemia
–Penetrating abdominal trauma in second, third trimester frequently
involves uterus
–Greatest danger from uterine injury is hypovolemia
Trauma in Pregnancy
•Assessment
–Second, third trimester blunt abdominal trauma may cause:
•Uterine rupture
•Placental abruption
•Premature labor
•Hemorrhage from uterine vessels
Trauma in Pregnancy
•Assessment
–“Loose” joints mimic orthopedic injury
–Particularly pelvic fracture
Trauma in Pregnancy
•Management
–Treat shock early, aggressively
•Fetus may be distressed when mother is not
•S/S of shock appear later
•More volume needed to correct hypovolemia
Trauma in Pregnancy
•Management
–Oxygenate aggressively
–Consider assisting ventilation early
•Oxygen demand increases 10-20% in last trimester
•High diaphragm causes decreased compliance, tidal
volume
Trauma in Pregnancy
•Management
–MAST can be used in late-term pregnancy
•Inflate legs only
•Using abdominal compartment reduces blood flow to fetus
Trauma in Pregnancy
•After first trimester never transport patient flat on back
–Transport on left side
–Prop up right side of spine board with blanket, pillows
Trauma in Pregnancy
•Most common cause of fetal death from trauma is maternal death
•Keeping mom alive keeps baby alive
•What’s good for mom is good for baby
Braxton-Hicks Contractions
•Usually occurs in the third trimester
•Benign phenomenon that simulates labor
•Contractions are generally painless
•Walking may help
Preterm labor
•Labor that begins prior to 38 weeks gestation
•Labor results in progressive dilation and effacement of cervix
•Causes
–Multiple gestations
–Intrauterine infections
–Premature rupture of the membranes
–Uterine or cervical anatomical abnormalities
Preterm labor
•Management
–Consideration of tocolysis
•Rest
•Fluids
•Sedation
–Transport for evaluation
Stay and Play, or Scoop and Swoop?!?!
•Options:
–Deny this day is happening!!!!!
–Transport
–Prepare for the delivery
Signs of Imminent Delivery
•Crowning
•Rupture of Amniotic Sac
•Need to bear down
•Sensation of needing to move bowels
•Contractions
–1 to 2 minutes apart
–Regular
–Lasting 45 to 60 seconds
Preparing to Transport
•O2
•Left Side
•IV
Preparing for Delivery
•Calm/supportive
•Position patient –supine
–Left lateral wedge
–pillow under hips
•Universal precautions
Preparing for Delivery
•Monitor FHT –Continuous
–Doppler every 5 minutes
•IV
•O2
Delivery
•Place gloved hand gently on presenting part
•On delivery of head, suction mouth then nose
•Feel around neck for presence of umbilical cord (nuchal cord)
–Slip off
–Clamp and cut if unable to remove
Delivery
•Gently guide baby’s head down to deliver upper shoulder
•Gently guide baby’s head up to deliver lower shoulder
•Gently assist with delivery of rest of baby; Do NOT pull
•Note time of delivery of baby
Delivery
•Clamp, cut cord
–First clamp about 4- 6” from baby
–Second clamp 2” further away from first
–Cut between clamps
–Use umbilical tape to control any bleeding from cord
Delivery
•Dry Infant
•Place hat
•Flick baby’s feet, rub back to stimulate
•Do NOT shake infant
•Do NOT slap buttocks
•“Blow by” O2 if:
–Heart rate < 100
–Persistent central cyanosis present
Delivery
•Resuscitate if necessary
•KEEP WARM
•APGARS
–1 minute
–5 minute
Delivery
•“Deliver” Placenta
–Place placenta in plastic bag and deliver to hospital to be
examined for completeness
–Uterine massage
–Pitocin 10-20 units/1000cc bag LR or NS
•Adjust rate to keep uterus firm and control bleeding
Abnormal Delivery Situations
Breech Presentation
•The buttocks or both feet present first.
•If the infant starts to breathe with its face pressed against the vaginal
wall, form a “V” and push the vaginal wall away from infant’s face.
Continue during transport.
Breech Presentation
Prolapsed Cord
•The umbilical cord precedes the fetal presenting part.
•Elevate the hips, administer oxygen, and keep warm.
•If the umbilical cord is seen in the vagina, insert two gloved fingers to
raise the fetus off the cord. Do not push cord back.
•Wrap cord in sterile moist towel.
•Transport immediately; do not attempt delivery.
Prolapsed Cord
Limb Presentation
•With limb presentation, place the mother in knee–chest position,
administer oxygen, and transport immediately. Do not attempt delivery.
Other Abnormal Presentations
•Whenever an abnormal presentation or position of the fetus makes
normal delivery impossible, reassure the mother.
•Administer oxygen.
•Transport immediately.
•Do not attempt field delivery in these circumstances.
Other Delivery Complications
Multiple Births
•Follow normal guidelines, but have additional personnel and equipment.
•In twin births, labor starts earlier and babies are smaller.
•Prevent hypothermia.
Cephalopelvic Disproportion
•Infant’s head is too big to pass through pelvis easily.
•Causes include oversized fetus, hydrocephalus, conjoined twins, or fetal
tumors.
•If not recognized, can cause uterine rupture.
•Usually requires cesarean section.
•Give oxygen to mother and start IV.
•Rapid transport.
Precipitous Delivery
•Occurs in less than 3 hours of labor.
•Usually in patients in grand multipara, fetal trauma, tearing of cord, or
maternal lacerations.
•Be ready for rapid delivery, and attempt to control the head.
•Keep the baby warm.
Shoulder Dystocia
•Infant’s shoulders are larger than its head.
•Turtle sign.
•Do not pull on the infant’s head.
•If baby does not deliver, transport the patient immediately.
Meconium Staining
•Fetus passes feces into the amniotic fluid.
•If meconium is thick, suction the hypopharynx and trachea using an
endotracheal tube until all meconium has been cleared from the airway.
Maternal Complications of Labor and Delivery
Uterine Rupture
•Tearing, or rupture, of the uterus.
•Patient complains of severe abdominal pain and will often be in shock.
Abdomen is often tender and rigid.
•Fetal heart tones are absent.
•Treat for shock.
•Give high-flow, high-concentration oxygen and start two large-bore IVs of
normal saline.
•Transport patient rapidly.
Uterine Inversion
•Uterus turns inside out after delivery and extends through the cervix.
•Blood loss ranges from 800 to 1,800 cc.
•Begin fluid resuscitation.
•Make one attempt to replace the uterus. If this fails, cover the uterus with
towels moistened with saline and transport immediately.
Pulmonary Embolism
•Presents with sudden severe dyspnea and sharp chest pain.
•Administer high-flow, high-concentration oxygen and support ventilations
as needed.
•Establish an IV of normal saline.
•Transport immediately, monitoring the heart, vital signs, and oxygen
saturation.
Maternal Hemorrhage: Postpartum
•500 cc blood loss or more during delivery
•True maternal emergency
•Place sterile pad over vaginal opening
–If bleeding is excessive:
•Rapidly transport to hospital
•Uterine massage
•Encourage breastfeeding if possible
Maternal Hemorrhage: Postpartum
•At risk:
–Diabetics
–Multiple births
–Severe IUGR (Intrauterine growth restriction)
–RH Isoimmunization (Rhogam)
–Maternal conditions
•Drug abuse
•Trauma
•Heart/renal disease
–Surgical complications
Maternal Hemorrhage: Postpartum
–2 large bore IVs
–1000cc NS or LR with 10-20 units Pitocin rapidly
–Methergine 0.2mg IM
–Hemanate IM if available
–PRBC
–Foley
–MAST
Obstetric Patient Assessment
Obstetric PA
•Recognition of pregnancy
–Breast tenderness
–Urinary frequency
–Amenorrhea
–Nausea/Vomiting
Obstetric PA
•Obstetric History
–Gravidity and Parity
•Gravidity = Number of pregnancies
•Parity = Number of live births
Obstetric PA
•Obstetric History
–Last normal menstrual period
–Estimated delivery date (-3/+7)
–Previous Ob-Gyn complications
–Prenatal care (by whom)
–Previous Cesarean sections
Obstetric PA
•Obstetric Physical Exam
–Evaluation of Uterine Size
•12 to 16 weeks: above symphysis pubis
•20 weeks: at umbilicus
•For each week beyond 20 weeks: 1 cm above umbilicus
•At term: near xiphoid process
Fundal Height Evaluation
Obstetric PA
•Obstetric Physical Exam
–Presence of fetal movements
•~20th week
–Presence of fetal heat tones
•~20th week
•Normal: 120 to 160/minute
Obstetric PA
•Presence of Pain
–Abdominal pain in last trimester suggests abruption until proven
otherwise
–Appendicitis may present with RUQ pain
Obstetric PA
•Presence of vaginal bleeding
–Always dangerous in first trimester
–Dangerous in late pregnancy if greater than normal period
Obstetric PA
•General health
–Diabetes may become unstable
•Hypoglycemic episodes in early pregnancy
•Hyperglycemia as pregnancy progresses
–Hypertension complicated by PIH
–Cardiovascular disease may worsen
Obstetric PA
•Do tilt test if blood loss is suspected
•Do NOT tilt patient with obvious shock
Obstetric PA
•Do NOT perform vaginal exams
Obstetric PA
•Warning signs
–Vaginal bleeding
–Swelling of face, hands
–Dimmed, blurred vision
–Abdominal pain
Obstetric PA
•Warning signs
–Persistent vomiting
–Chills, fever
–Dysuria
–Fluid escape from vagina
OB Pharmacology
•Mag Sulfate
•Pitocin
•Terbutaline
Magnesium Sulfate
•Actions
–Not clearly understood
–Seems to decrease release of acetylcholine at neuromuscular
junction
–Depresses central nervous system
–Causes mild vasodilation
•Decreases blood pressure
•Improves placental blood flow
Magnesium Sulfate
•Indications
–Anticonvulsant effects in:
•Pre-eclampsia
•Eclampsia
Magnesium Sulfate
•Contraindications
–Renal disease
–Cardiac failure
–AV conduction defects
–Myasthenia gravis
Magnesium Sulfate
•Adverse effects
–Muscle weakness
–Respiratory depression
–Hypotension
–Slowed cardiac conduction/AV blocks
Magnesium Sulfate
•Antidote to toxic effects
–Calcium
Magnesium Sulfate
•Dose
–Initial: 4 to 8 gm IV over 20 minutes
–Maintenance: 1 to 2 gm/hr
Pitocin
•Action
–Synthetic oxytocin
–Stimulates uterine smooth muscle contraction
Pitocin
•Indication
–Control of postpartum hemorrhage
Pitocin
•Contraindication
–Do not administer until after baby, placenta fully delivered
–May cause trapping of placenta or second twin in uterus
Pitocin
•Adverse effects
–Nausea, vomiting
–Cardiac arrhythmias
–Fluid retention with water intoxication
–Transient vasodilation, reflex tachycardia
Pitocin
•Dose
–10 to 40 units in 1 L of crystalloid
–Infuse to:
•Sustain uterine contraction
•Control hemorrhage
Terbutaline
•Class
–Sympathetic agonist and tocolytic
•Description
–A synthetic sympathomimetic that is selective for β2-adrenergic
receptors
Terbutaline
•Mechanism of Action
–Causes immediate bronchodilation with minimal cardiac effects
–Stimulation of β2-adrenergic receptors in the uterus causes uterine
relaxation and can suppress labor.
Terbutaline
•Pharmacokinetics
–Onset
•< 15 minutes (SC)
–Peak effects
•30-60 minutes (SC)
–Duration
•1.5-4.0 hours (SC)
–Half-life
•3-4 hours
Terbutaline
•Indications
–Preterm labor
•Contraindications
–Known history of hypersensitivity
•Precautions
–Caution should be used with:
•Elderly patients
•Cardiovascular disease
•Hypertension
–V/S must be monitored
Terbutaline
•Side Effects
–Palpitations
–Anxiety
–Dizziness
–Headache
–Nervousness
–Tremor
–Hypertension
–Dysrhythmias
–Chest pain
–Nausea and vomiting
Terbutaline
•Interactions
–Unpleasant side effects increase when used with other
sympathetic agonists
–β-blockers may blunt the pharmacological effects of terbutaline
•Dosage
–Initial dose should be 0.25 mg SC
–Can be repeated in 30-60 minutes
–Maintenance drip can be used
•Placing 5 mg in 500 mL of lactated Ringer’s solution or
normal saline
•30 mL/hr (5 mg/min)
•Can be slowly increased to a maximum dose of 80 mg/min