LEC 9: Obstetrical Emergency Flashcards
1
Q
Complications in Labour and Delivery
A
- Dystocia
- Preciptious labour and delivery
- Malpresentation/ Position
- POP
- Breech and ECV
- Operative and assisted deliveries
- Caesarean birth
- Forceps/ Vaccuum
- TOLAC/ VBAC
- Obstetrical emergencies
- Shoulder dystocia
- Cord prolapse
2
Q
Dystocia
A
- Abnormal or difficult labour
-
Problems with powers
- Hypotonic or hypertonic uterine contraction
- Arrested labour
- Preciptious labour (<3 hours)
-
Problems with Passenger
- POP
- CPD
- Breach
- Shoulder systocia
- Cord prolapse
- May result in
-
Operative delivery
- Forceps, vacuum, c-section
-
Operative delivery
3
Q
Breach Presentation
A
- 3 to 4% of all term pregnancies
- Frank
- 50 to 70%
- Footling
- 10 to 30%
- Complete
- 5 to 10%
- Frank
4
Q
Diagnosis of Breech
A
- Maternal
- Leopold’s Maneuver’s
- FH auscultated above umbilicus
- Vaginal examination
- Ultrasound
- Meconium (if ROM)
5
Q
Fetal Risks
A
- Cord prolapse more likely with ROM
- Traumatic injury to the aftercomin head can → intracranial hemorrhage of anoxia
- Preterm breech: Footlin and body may deliver before full dilation → entrapment
6
Q
2009 SOGC - Vaginal Delivery of Breech
A
- Vaginal delivery os the best method of delivering an uncompliated term, frank, of complete breech, singleton, ?35oo and <4000g with flexed ehad
7
Q
External Cephalic Version
A
- Ultrasound
- Reactive NST
- Can’t be engaged
- Tocolytic to relax uterus
- Risk of nuchal cord
- Fetal monitoring
- Monitor for SOL
8
Q
A
9
Q
Types of Operative Delivery
A
- Cesarean birth
- Operative vaginal delivery
- Forceps
- Vaccum
10
Q
Indications for C-Section
A
- Can be planned or unplanned
- Non-reassuring fetal heart rate findings
- Active genital herpes
- Multiple gestation (three or more fetuses)
- Umbilical ccord prolapse
- Pelvic size (tumors that obstruct birth canl, cephalopelvic disproprotion_
- Lack of labour prgression/ failed induction
- Maternal infection/ severe disease
- Placenta previa
- Previous cesarean section (relative)
- Fetal anomalies or extremes in size (low, high)
11
Q
C-Section Incision
A
- Transverse in lower segment
- Vertical in lower segment
- Classical incsision: in body of the uterus
- Wounds are closed based on physican specific
- Important to look at the incision before sending someone home
- Usually take out incision on post-op day 5
- Can be doen at home by healthy-and-home or got ot their physicians office
12
Q
Women who have C-Section are at Increased Risk For:
A
-
Intra-Opeative
- Aspiration
- Difficult airway managment
- PPH (>100 mls)
-
Post-Op
- Endometritis/ Infection
- Hemorrhage
- Poor bladder emptying
- Paralytic ileus (rare)
- Thrombophlebitis
13
Q
Preparation in C-Section
A
- Cesarean birth requires
- Establishing IV lines
- Placing indwelling catheter
- Performing abdominal prep
- Ranitidine or sodium citrate
- NICU
- Teaching Needs Include
- What to expect before, during, and after delivery
- Why is it being done
- What sensations will the woman experience
- role of significant other
- Interaction with newborn
14
Q
Post-op/Post partum
A
- Pain
- Analgesia/ antiemetic. antipruritic
- Naproxen PRN for vaginal delivery
- C-Section: Naproxen is scheduled for first 24 hours and then PRN
- Comfort measures
- Assess fro hemmorhage
- Assess for infection
- Get her MOVING
- Postpartuma nd postoperative checks
- Fatigue: Different for scheduled vs. non-scheduled c-section
- Attention to fatigue
15
Q
A
16
Q
Trial Of Labour After Cesarean Section (TOLAC)
A
- Depends on indication and type of 1st section, maternal health
- Most common risks:
- Hemorrhage
- Uterine rupture - Complete separation of the myometrium with/ without extrusion of fetal parts into the maternal peritoneal cavity
- Infant death or neurological complications
- Successful TOLAC becomes VBAC
- Fetal monitoring
- Avoid cervical ripening
- Need to be papered for c-section quickly if things go wrong
17
Q
Operative Vaginal Birth: Indications
A
- Fetal indications
- Non-assuring fetal heart rate
- Maternal
- Exhaustion or inability to push
- Lack of rotation
- Maternal disease
18
Q
Operative Vaginal Birth: Intervnetion During
A
- Support and educate
- Fetal heart assessment
19
Q
How can we prevent operative vaginal birth?
A
- Support throughout labour
- Mobility
- Positionc hanges
- Rest
- Keep bladder empty
- Well hydrated and nourished
20
Q
Important Considerations in Forceps/ Vaccuum
A
- Need to be completely dilated/ membranes ruptured
- Empty bladder
- May need an in-and-out catheter
- Fetal position known/ adequate pelvis
- Analgesia if able
- If it is a failed forceps and vacuum = C-section
21
Q
Forceps
A
- Applied by a physician
- Downward pressure and then upward once the larges part of the head has come through
- Would be done while a women is pushing
- Fetal scalp is visible- presenting part is 2+- head is clearly engaged
22
Q
Vacuum Extractor
A
- Suction applied to fetal head (occiput)
- Should be progressive descent with first two pulls (with contractions) Used during contractions and pushing
- Geneally would not do more than 3 pulls
23
Q
Complications with Operative Vaginal Births: Newborn
A
- Common
- Bruising
- Laceration
- Edema
- Uncommon
- Renal hemorrhages
- Nerve injury
- Cephallhematoma
- Cerebreal hemorrahge
- Skull fracture (forceps)
- Intracranial bleeding, subgaleal hemorrhage (vaccuum)
- Watch for hyperbilirubinemia
24
Q
Complications with Operative Vaginal Births: Woman
A
- Genital tract trauma
- Increased bleeding
- Risk for PPH
- Bruising and edema
- Shoulder dystocia
25
Nursing Care During
* Attention to bladder
* Assessment of fetal well being throuhout
* Documentation
* Ease of application
* Timeon, off, number of pulls
* Difficulties suchas pop-offs
26
Nursing Care After
* Maternal
* PPH: Lacerations, atony
* Analgesia
* Watch for hematome
* Neonatal
* Trauma/ injuries
* Jaundice
27
Shoulder Dystocia
* Anterior shoulder impacts against maternal symphysis pubis
* Fetal shoulder do not deliver spontaneously
* Failure to deliver with expulsive effort and usual maneuvers
28
Major Risk Factors for Should Dystocia
* Maternal obesity
* Macrosomic infant
* Hisotry where a baby had should dystocia
* If you can mange diabetes = less risk
* Non-Diabetic
* babies \>4000 gms 4%
* babies \>4500 gms 10%
* Diabetic:
* babies over 4000 gms 15%
* babies \>4500 gms 42%
29
Turtle Sign
* Nuco-cord x3- risk- cord around the neck and quite tight
* Turtle sign is a heralding sign of shoulder dystocia
30
Shoulder Dystocia: ALARER
* Ask for help
* Lift / hyperflex legs
* Anterior shoulder disimpaction
* Rotate posterior shoulder
* Manual removal of posterior arm
* Episiotomy
* Roll over onto ‘all fours’
* Do not see often
31
McRobert’s Manoeuvre
* Before McRoberts Positioning: Diagonal orientation of symphysis makes shoulder delivery difficult
* McRobert’s Maneuver: Pelvis tilts, orienting symphysis more horizontally to facilitate should delivery; looks like knees to ears
32
Suprapubic Pressure
* NOT fundal pressure
* Lateral pressure in direction of fetal nose
* Protect your back
* Support/ inform patient and support person
33
Shoulder Dystocia Complications: **Maternal**
* Episotomy
* Extended lacerations
* Hematomas
* Uterine atony
* Hemorrhage
* Bladder injury
* Rectal injury
34
Shoulder Dystocia Complications: **Fetal**
* Number of clavical or humerus
* Brachial plexus injury or spinal nerve damage
* Erb's palsy
* Asphyxia
* Death
35
Cord Prolapse
* Obstetrical emergency
* Sudden, severe, variable decelerations or no fetal heart
* Feel or see cord
36
Cuases of Cord Prolapse
* Polyhydramnios
* Long cord
* Malpresnetation (breech, transverse)
* Premature rupture of membranes
* Amniotomy before engaged vertex
37
Obsterical Emergency
* Precaution - Always check fetal heart after ROM!!
* Get help, Prepare for Cesarean section delivery
* Keep pressure (presenting part) OFF cord
* Trendelnburg, Knee-chest position
* Keep hand in vagina
* ↓ contractions if able
* Warm wet sterile cloth if outside vagina
* Vaginal delivery only if fully dilated
