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OB Emergencies
Debbie Sibley, MSN, RNC-OB
Clinical Nurse Specialist
Women’s Services
The Medical Center of Central Georgia
Educational Objective
• Identify key elements to facilitate OB emergency
situations.
Maternal – Fetal Assessment
• Maternal Vital Signs
• Uterine Activity
• Resting Tone
• Intensity
• Frequency
• Duration
• Fetal Heart Rate (110-160 bpm)
• Baseline Rate
• auscultate x 6 secs (before, during and after contraction)
• Regular or Irregular?
• Decelerations Noted?
Fetal Position and Presentation
Leopold’s Maneuvers
Pregnancy Induced Hypertension
Preeclampsia is
diagnosed by the
development of
hypertension plus
proteinuria, or edema that
is generalized and overt, or
both.
Source: Williams Obstetrics
Grade III Placenta
Infarcted areas (dysfunctional)
and blood clots
PIH / Toxemia Only Worsens
There is One and Only One
“Cure” … Delivery
Eclampsia
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Turn patient on side
Protect from harm
If possible, insert oral airway. Do not force.
Call MD, summon help
Magnesium Sulfate
After seizure, administer O2
Suction nose and mouth
Note characteristics of seizure
Assess for abruption and imminent delivery
Magnesium Sulfate: Maternal Considerations
• 6 gm bolus has much better success at achieving and
maintaining target serum levels than 4 gm bolus.
• Magnesium Sulfate levels are not an absolute requirement if
you watch renal output.
• Watch out with Kidney Disease. Urine maybe excreted but
without any removal of wastes.
• “Magnesium Levels > 8, turn off even if she is breathing.”
(Devoe)
• The gold standard before and after delivery.
Magnesium Sulfate: Neonatal Considerations
• 2.4 Mag Level is HIGH
• May last for 24 – 48 hours
• Infant can be deceptively pink around the face, lips
and neck
• If symptomatic . . . TREAT!
• Watch for these in the neonate…
– B/P drops: Give N/S bolus
– Ileus: NPO
– Apnea: Intubate
Diabetes: Maternal Complications
Cesarean Births (41%)
Infections
Toxemia / PIH / preeclampsia
Hydramnios / polyhydramios
Shoulder dystocia (9.2% to 24% and 50% with babies
weighing >4500g)
Diabetes Ketoacidosis (rare)
Diabetes: Neonatal Complications
• Macrosomia (40% even with euglycemia)
predisposes baby to traumatic injuries:
• hyperbilirubinemia: 20%
• fractured clavicle
• Hypoglycemia: <35mg/dL (20%)
• Polycythemia: hematocrit >65% (3-5%)
• Anomalies:
• cardiac anomalies
• sacral agenesis
• RDS: incidence is decreased with maternal
euglycemia
Pregnancy is a Diabetogenic State…
Hyperglycemia plus hyperinsulinemia provide a
continuous supply of glucose to the fetus.
Insulin Needs Change Dramatically
• < 16 weeks: insulin requirements decrease
• 28 – 32 weeks: marked increase related to increased
fetal growth
• Immediate Postpartum: insulin needs drastically drop
Glycemic Goals and Lab Tests
• Pregnancy Glycemic Goals: serum blood glucose 6090 mg/dl fasting and overall goal of 80-120 mg/dl
• Hemoglobin A1C (glycosylated hemoglobin): mean
blood glucose over the last 3 months; normal values
are 4.2% to 6.1%
Classic Signs of Diabetes Ketoacidosis
• Polyuria
• Polydipsia (thirst)
• Polyphagia (increased appetite)
Additional S&S of DKA
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Abdominal pain
Dehydration
N&V
fruity (acetone) breath
Kussmaul breathing (air hunger, labored breathing)
Ketonuria & Glucosuria
Decreased Level of Consciousness (drowsiness,
coma)
DKA Mortality Rates
Maternal Mortality: rare
Fetal Mortality: 10% up to 35%
DKA Treatment
Aggressive Hydration
Administer Insulin
– IV regular insulin: flush polyvinyl tubing with 50mL to
allow saturation of insulin to tubing.
– Administer subcutaneous NovaLog insulin to give
coverage until IV insulin can be setup.
Fetal Assessment
– FHR: Palpate maternal pulse, auscultate FHR and
then compare findings of each.
– EFM: absent variability and late decelerations, but
don’t crash for C/S until ketoacidosis resolves.
Placenta Previa: Partial Previa
The placenta lies low in the
uterus, partly or completely
covering the cervix.
Occurs in one in 200 women.
Complete Previa
Abruption
• Measured in percentages
or centimeters
• The placenta may detach
from the uterine wall before
or during labor.
• Occurrence: 1% of all
pregnant women
• Abdominal pain is often a
classic sign even if there is
no obvious bleeding.
Complete Abruption
Couvelaire Uterus
Intrauterine Resuscitation
• Oxygen at 10 L/ min per non-rebreather face mask
0
• Change position: from HOB ↑ 30 to left or right
lateral
• IV Fluid Bolus: 1000mL over 20 minutes
• Stop Uterine Contractions: Give Terbutaline
(Brethine) or Magnesium Sulfate
• Notify care provider
Simpson and James. Efficacy of Intrauterine Resuscitation in Improving
Fetal Oxygen Status During Labor. Obstetrics & Gynecology 2005.
Maternal Positions and Cardiac Output
(liters / minute)
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KNEE - CHEST
RIGHT LATERAL
LEFT LATERAL
SITTING
SUPINE
DORSAL LITHOTOMY
STANDING
NON-PREGNANT
6.9
6.8
6.6
6.2
6.0
5.8
5.4
5.5
best!
#2
#3
#4
bad!
bad!
worst!
Clark and Cotton Am J Obstet Gynecology 1989
Emergency Delivery
Don’t Leave Her Unattended
Don’t Run
Don’t Panic!
(Don’t Break The Bed)
Don’t Hold Legs Together
Cord Management
Suction Mouth Then Nose
Note Time of Delivery
Thermal Regulation: Keep Baby Warm
Transportation of Mother & Baby
Breech Extraction Without Forceps
Additional OB Emergencies
Shoulder Dystocia: No Fundal Pressure, even if
called for by OB care provider
Maternal Deaths Decline Sharply Across the Globe
Worldwide decrease from 526,300 (1980) to approximately
342,900 (2008)
Reasons: reduced pregnancy rates; higher income, (better
nutrition and access to health care); increased education for
women; and increased availability of trained attendants
assisting with childbirth.
Study was conducted at the University of Washington and
University of Queensland in Brisbane, Australia. Funded by
the Bill and Melinda Gates Foundation.
The researchers analyzed maternal mortality in 181 countries
between 1980 and 2008.
Sub-Saharan Africa has highest maternal death rates and
improvements in India and China maternal death rates.
From Lancet reported in AWHONN Vitals May 2010
Leading Causes of Maternal Death
Embolism: leading cause after live birth
Hemorrhage: leading cause after stillbirth
Hypertension
Infection
Other medical conditions: leading cause when undelivered
Indirect Causes: Cardiomyopathy / Heart Disease, Homicide,
MVA, Cancer and Suicide
Centers for Disease Control and Prevention (CDC),
http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5202a1.htm
Cardiac Arrest and Pregnancy
• For both maternal and fetal outcome, early C/S
(within 4 – 5 minutes of maternal cardiac arrest)
appears to offer best chance of survival
• Continue CPR and ACLS protocols during the
perimortem cesarean delivery to maximize maternal
and placental perfusion
• OB anesthesiologist becomes “Captain of the Ship”
Modifications of CPR and Pregnancy
• Uterine Displacement
• Airway Management
• Deeper Chest Compressions
• Deliver within 5 minutes if viable fetus
Uterine Displacement
Why?
– to decrease compression of abdominal aorta, inferior
vena cava and iliac arteries
How?
– Manual displacement of the uterus
– Rolled towel or wedge under her hip (decreased
effectiveness of chest compressions)
– “Human Wedge”
Maternal Position and Hysterotomy Decisions
Gestational Age
>24 wks (4+ and higher):
improves maternal cardiac
output & infant survival
20-23 wks (umbilicus to 3+):
improves maternal cardiac
output
<20 wks (below umbilicus):
No C/S; uterine size not
compromising maternal
cardiac output
Uterine Displacement If Greater Than 20 Weeks…
Create a “Human Wedge”
• Roll patient to side (left or
right)
• Tilt patient on the bent
knees of the rescuer
Open Airway in Pregnancy: Jaw Thrust
Open Airway: Head Tilt , Chin Lift
Airway Changes: Use Cricoid Pressure
Larynx is more anterior & cephalad; Laryngeal
& pharyngeal mucosa more edematous
Resuscitation Needs
• Smaller Endotracheal Tube
• Short Laryngoscope Handles
• Equipment for Cricothyrotomy
Incidence of failed intubation 1:500 compared to
general surgical population 1:2000
Chest Compressions
• Use additional pressure with chest compressions
• Compress Chest 2 inches (push deeper)
• Compressions: “Deep and Fast”
Deliver within 5 minutes if viable fetus
Initiate C/S within 4 minutes and Deliver
Infant within 5 minutes of arrest
• Maternal Survival
Highly linked with cause of arrest (Amniotic Fluid Embolus,
Gun Shot Wound, et al.)
Many cases CPR/ACLS ineffective until delivery, followed
by dramatic recovery
• Fetal Outcome
Viable >23 weeks gestation
Delivered within the first five minutes of maternal cardiac
arrest
Perimortem Cesarean Birth Outcomes
Clark and Cotton, Kantz
Maternal Death to Delivery
Outcome
0-5 minutes
42 Normal
6-10 minutes
7 Normal
1 mild neurological sequelae
11-15 minutes
6 Normal
1 severe neurological sequelae
16-20 minutes
1 severe neurological sequelae
21+ minutes
2 severe neurological sequelae
1 Normal Infant
Survivability of Infants
Christopher Viscomi, Anesthesiologist, University of Vermont
Arrest to Delivery
Fetal Survival
Intact Survival
< 5 minutes
>95%
>95%
5-10 minutes
80-85%
80%
10-20 minutes
35%
20%
>20 minutes
10%
5%
ACLS Protocol
Primary Survey
Airway: open airway
Breathing: PPV
Circulation: perform chest compressions
Defibrillation: shock for VF and pulseless VT
ACLS Protocol
Secondary Survey
Airway: establish advanced airway/ET intubation
Breathing: assess adequacy of ET intubation & PPV
Circulation: IV access, continue CPR and
Defibrillate up to 3 times 200 J, 200-300 J and 360 J
Permission for use has been granted: Lippincott Williams & Wilkins
Cardiac Arrest and Pregnancy Protocol
• (BLS Box 1) Check for Response.
– Tap on shoulder & ask, “Are you all right?” No movement.
No response.
– Victim assessed to be pregnant.
• (BLS Box 2) Activate EMS: Phone 911 Call OB
code team / “Code Blue”
• (BLS Box 2) Get AED. Return & Perform CPR.
Permission for use has been granted: Lippincott Williams & Wilkins
Cardiac Arrest and Pregnancy Protocol
• (BLS Box 2) Position the victim.
– Place victim supine on hard surface.
– Fundal height. Above umbilicus: uterine tilt. Below: proceed without
modifications.
– Rescuer kneels beside victim’s thorax.
– Do not move the victim unless environment becomes unsafe.
• (BLS Box 3) Open Airway
– Jaw thrust (with cricoid pressure).
– If adequate ventilations cannot be effected, use head tilt-chin lift (with
cricoid pressure).
• (BLS Box 3) Maintaining Open Airway, Check breathing:
“Look, Listen, and Feel” (<10 seconds)
Cardiac Arrest and Pregnancy Protocol
• (BLS Box 4) No breath: Perform Rescue Breathing.
– Pinch victim’s nose, create airtight mouth-to-mouth seal.
– Give 2 rescue breaths. Effect visible chest rise.
– No rise and fall with first breath, reposition. Perform head
tilt-chin lift and give second breath.
– Each rescue breath should be delivered over 1 second
per breath. Avoid rapid or forceful breaths.
– Rescuer should take “regular” (not deep) breaths
between rescue breaths.
– Continuous cricoid pressure with rescue breathing and
during intubation.
– Establish advanced airway early with smaller
endotracheal tube. (# 6.5 or # 7)
Permission for use has been granted: Lippincott Williams & Wilkins
Cardiac Arrest and Pregnancy Protocol
• (BLS Box 5) Pulse Check: Complete within 10
seconds. Recheck and change roles every 5
cycles.
– Feel for pulse at the carotid. No pulse: begin chest
compressions.
Cardiac Arrest and Pregnancy Protocol
• (BLS Box 6) Give Chest Compressions (one cycle = 30
compressions & 2 breaths)
– Rescuer’s position: kneel at victim’s thorax
– Chest Compression location: mid-sternum, between the nipples
– Hand position: heel of hand on sternum, other hand on top
(overlapped & parallel)
– Chest Compression Rate: 100 per minute. “Push hard, push fast.”
– Chest Compression Depth: 1½” to 2” (deeper with additional
pressure)
– Universal Compression-Ventilation Ratio 30:2 (with one or multiple
rescuers)
– Allow complete chest recoil
– Minimize interruptions, especially avoiding prolonged interruptions of
chest compressions.
– Use prompts: 2nd rescuer’s arrival: “I Know CPR” & 2-man CPR:
audible counts.
Permission for use has been granted: Lippincott Williams & Wilkins
Cardiac Arrest and Pregnancy Protocol
• (BLS Boxes 7, 8 & 9) At 2 minutes (5 cycles
completed): analyze, “all clear” & defibrillate.
Shockable rhythm: Give one shock. Use same
joules/dose & pad placement. Non-shockable:
resume CPR.
• (BLS Box 10) Resume CPR, begin with chest
compressions. Check rhythm, change roles Q 5
cycles.
– Establish central access: subclavian; consider
endotracheal tube route for meds. (ACLS)
– Administer medications. Use same doses as ACLS
protocols. Consider differential diagnoses. (ACLS)
Cardiac Arrest and Pregnancy Protocol
• Near 4 minutes: Five cycles of CPR given &
defibrillation completed. Make cesarean decision.
• At 4 minutes: begin cesarean if needed equipment,
skills and personnel are available.
• At 5 minutes: deliver baby, change compressor
role. Provide continuous CPR throughout surgery.
• At 15 minutes CPR remains inadequate: consider
direct cardiac massage or cardiopulmonary bypass.
Life Saving Cesarean Birth
Initiate C/S within 4 minutes and deliver
Infant within 5 minutes of arrest
• Maternal Survival
Many cases CPR/ACLS ineffective until delivery, followed
by dramatic recovery
• Fetal Outcome
Viable >23 weeks gestation
Delivered within the first five minutes of maternal cardiac
arrest
Stay Calm: Initiate techniques to counteract our
sympathetic response
Triage: Assess airway, breathing and circulation
Assess: Rapid maternal assessment with
emphasis on pulmonary, cardiovascular and
neurologic status
Baby: Assess viability and gestation age
Launch: Protocols, IV access, O2 and fluid
replacement
Evaluate & Evacuate: patient’s responses and
stability for transport
Cardiac Arrest and Pregnancy Protocol
• 1999. Johnson, Luppi and Over. AWHONN’s
Lifelines. “Cardiopulmonary Resuscitation in
Pregnancy.”
• 2005. American Heart Association’s Pregnancy
Modifications. Circulation. Part 10.8
http://circ.ahajournals.org/cgi/content/full/112/24_su
ppl/IV-150
• 2005. AHA Basic Life Support (BLS) Guidelines
• 2005. Advanced Cardiovascular Life Support
(ACLS) Guidelines
References
• AAP and ACOG. Guidelines for Perinatal Care.
Sixth Edition. 2007
• ACLS: American Heart Association’s 2005
Advanced Cardiac Life Support Guidelines
• ALSO: American Academy of Family Physicians’
Advanced Life Support in Obstetrics
http://www.aafp.org/
• AWHONN. Perinatal Nursing. 2008.
Questions… Answers…Rebuttals…
OB Emergencies
Transport Conference 2010
Debbie Sibley, MSN, RNC-OB
Women’s Services Clinical Nurse Specialist
The Medical Center of Central Georgia
Macon, Georgia
Phone: 478-633-7307 Email: [email protected]