Labor and Jehova Witness Flashcards
are you concerned that pt is jehovas witness
yes I am concerned about a pt who may not accept the administration of blood products especially since she is at increased risk for several complications that could lead to blood loss
1) TOLAC increases risk uterine rupture
2) adhesions and scarring from previous section could potentially lengthen and complicate a C section should it be required
3) elevated blood pressures and hx suggest preeclampsia which may affect hemostasis
4) increased risk uterine atony due to her grand multiparity and administration of mg for preeclampsia puts her at increased risk atony
what would you discuss with the patient given this information
I would have discussion with her and her OB about risks of bleeding during this case and increased risk of morbidity and mortality if blood product transfusion was not an option
I would ask them to consider elective C section bc of risk of uterine rupture
ask pt if they would allow albumin administration or intraop blood salvage with blood remaining in continuity with her circulatory system
She says that she experienced prolonged motor and sensory loss following previous epidural for vaginal delivery, shes afraid to have another one. What do you say
I would first review the chart and ask the patient for details concerning the sensory and motor loss and how long it lasted as well as what area was effected
I would then make a rec to the pt explaining my reasoning for that rec
I would inform her that most peripheral nerve palsies are obstetric in origin due to positioning of pt or instrumentation during vaginal delivery and/or 2/2 to compression of nerves as the baby’s head crosses the pelvic brim
anesthesia rarely causes persistence of motor or sensory block beyond 24 hours
I would also let her know there were alternative methods of pain control like IV narcotics, NSAIDs, lamaze, TENS but epidural anesthesia tends to provide superior analgesia.
Also given the high risk of the procedure would provide potential alternative to GA in the case of emergency C section
The patient asks if there are any other options for regional analgesia?
other options would include a paracervical block for the fist stage of labor and a pudendal block with simultaneous infiltration of the perineum for the second stage of labor
Paracervical bocks have a risk of fetal bradycardia and decreased UP perfusion. The potential UP insufficiency associated with preeclampsia makes this inappropriate regional choice for this patient
Since maternal or fetal complications from a pudendal block like intravascular injection, retroperitoneal hematoma, and abscess are uncommon this would be appropriate for labor coupled with other means of analgesia for the first stage of labor
a couple of hours later, pt decides she wants an epidural but you are currently tied up and cannot consent her for 30-45 minutes. Nurse asks if she can give nalbuphine to help with discomfort until you arrive. Would you delay this until consent could be obtained
While consent would ideally be obtained prior to any premedication I would not dealy it given that the relief of pain may enhance her ability to provide adequate consent. I do understand that giving too much could render her unable to understand the risks and benefits associated with the planned procedure. Therefore I would titrate the medication carefully
describe how you would place an intraosseous line
I would insert an IO needle into the tibia at a 10-15 degree caudal angulation1-2 cm below and 1 cm medial to the tibial tuberosity
I would then advance the needle until I felt a pop or reduced resistance and confirm placement with aspiration of bone marrow
I would then ensure that fluids flowed freely through the line without signs of extravasation
baby delivered vaginally and there is an abnormal amount of bleeding likely a uterine tear and OB wants to go to the OR. She loses IV access on the way and you cannot place another PIV. What would you do
apply oxygen, place monitors, attempt central line
if cannot then call for surgeon to perform cut down for IV access and/or attempt to place IO
could use the IO for drug admin and volume ressucc while trying to place other lines
I would also call for intraop blood salvaging if pt had agreed to this, volume expanders, emergency drugs
what are some of the complications associated with IO access
compartment syndrome (extravasation)
muscle necrosis
osteomyelitis
bacteremia
cellulitis
growth plate injury
finally get CVC would you place A line and PAC
I would place an A line due to the risk of significant anemia and hemodynamic instability along with lab abnormalities
I would place after induction because this is an emergency case that has no time to wait
PAC can help guide CO and PVR but I would avoid placing this unless absolutely necessary given the increased risk for pulmonary artery rupture and coagulopathy 2/2 thrombocytopenia, or DIC in this pt with preeclampsia, exposure to amniotic fluid, and significant blood loss
Patient’s blood pressure is now 88/63. Would you perform RSI
I would not due to risk of difficult airway managements 2/2 to patients pregnancy, obesity, and preeclampsia
Large bolus drugs could also lead to hemodynamic instability in the setting of hypovolemia and anemia
However I understand that this patient is at increased risk for aspiration due to changes with pregnancy therefore I would provide aspiration ppx and utilize neuraxial anesthetic for the procedure
patient continues to bleed and hgb is now 4.8, would you give blood
I would let the surgeon know of the critically low hgb deliver 100% oxygen and ensure adequate volume replacement, institute intraop blood salvage only if she had agreed prior, otherwise I would not administer any blood products
a patient has the legal right to decide to forgo clinically necessary treatment if the patient is judged to be competent
patients neck begins to swell where you previously attempted to place the CVC in the IJ. What do you think is going on?
swelling probably from renewed bleeding at site 2/2 to developing coagulopathy
could be from fibrinolysis, hypofibrinogenemia, dilutional coagulopathy, DIC ,hypothermia
what are her risk factors for developing DIC
1) uterine rupture extending beyond old scar with exposure of vasculature to amniotic fluid rich in procoagulant thromboplastins that can lead to DIC
2) hypovolemia and low pressures which further increase risk of amniotic fluid entering intravascular system to make her less able to wash out accumulation of intravascular coagulation factors
3) extensive vascular endothelial damage that occurs with preeclampsia which further predisposes her to DIC
what is DIC
disseminated intravascular coagulation is a pathological activation of the coagulation cascade associated with a variety of conditions
wide spread formation of small clots in blood vessels throughout the body results in consuption of coagulation factors, thrombocytopenia, hemolytic anemia, diffuse bleeding and thromboembolic phenomena
labwork: fibrinogen < 100, thrombocytopenia, decreased antithrombin III levels, presence of fibrin degradation products and D dimer
you ended up transfusing lots of products. You visit the patient a few hours later and she is breathing easily but her CXR is showing pulmonary edema. What do you think is the etiology of her pulmonary edema
most likely transfusion associated circulatory overload (TACO) 2/2 to large volumes of fluids and blood product from resuscitation
the increased pulmonary blood flow that occurs with severe anemia and or fluid overload can raise pulmonary capillary pressures to the point where pulmonary edema occurs
increased pulmonary capillary permeability associated with preeclampsia likely contributed
other potential cuases could be ARDS, TRALI
