OB Flashcards
What is the Pinard Maneuver
Used for breech deliveries.
Abduct the hip by pushing laterally on the inner aspect of the knee.
Flex the knee and sweep the foot and leg medially, maneuvering it downward to deliver.
Magnesium dose for preeclampsia, eclampsia, or PIH
6g/100ml over 30 minutes. If actively seizing administer over 15 minutes.
Maintenance: 4g/100ml NS or 10g/250ml. Infuse at 2g/hr IV. (50ml/hr)
Meg toxicity reversal
1G calcium gluconate over 3-5 minutes, redose PRN
Seizure management in eclampsia
Administer additional 2G mag over 2 minutes.
Increase infusion by 1G/hr
If seizure persists more than 2 minutes, lorazepam.
BP management in pre-e, eclampsia and PIH
SBP >160 and DBP>110
Labetalol or Hydralazine
Labetalol dose for BP management
20mg IV over 2 minutes
wait 10 minutes, then
40mg IV over 2 minutes
wait 10 minutes, then
80mg IV over 2 minutes.
Consider drip (1-2mg/min)
(max 300mg in 24 hours)
Hydralazine dose for BP management
5mg over 1 minute
wait 10 minutes, then
additional 5-10mg IV q20min.
Max cumulative dose of 20 mg
consider drip at 0.5-10mg/hr.
Medications for preterm labor
Nifedipine, magnesium sulfate, terbutaline
Nifedipine dose for preterm labor
10mg SL/PO q15min, max total dose 40.
Magnesium Sulfate dose for preterm labor
6g/100ml IV administered over 30 minutes.
Maintenance: 4G/100ml or 10G/250ML, infuse at 2G/hr.
Magnesium monitoring
- DTR q5m x 3, then q15m
- RR
Magnesium toxicity
Calcium Gluconate
1G over 3-5 minutes, redose PRN.
Terbutaline dose
0.25mg SQ q30m until tocolysis achieved.
Max 3 doses
Hold for pulse >120
PROM
- Document time of rupture
- Consult with physician regarding abx prior to transport if febrile or GBS positive
- Consult with physician regarding betamethasone
- Avoid letting patient stand or ambulate.
Progression threshold for transport
5cm dilated or 100% effaced
consult with sending provider to ensure appropriateness of transport.
S/S of impending delivery
- Sensation of impending defecation
- urge to push
- crowning
Betmethasone
24 0/7 – 36 6/7
12MG IM x1 per order of sending or receiving physician.
Assessment and management of OB transport
- Maternal vitals and O2 sats
- document FHR q15
- additional assessment per guidelines as indicated
PPH Interventions
After placenta delivery:
Fundal massage
Oxytocin
Consider transfusion
Methergine
Oxytocin for PPH
40 units in 1000ml
500ml over 10 minutes
50ml/hr
10 units IM if no IV available
After delivery of placenta
Methergine for PPH
*If oxytocin fails to produce adequate uterine contraction
0.2MG IM q2-4hrs
Do not administer in patients SBP>140
*Consult with provider or OLMC
Trauma in pregnancy
- determine mechanism of injury
- inspect abd and distinguish pain from contractions
- Assess for chest injury
- serial assessments of abd and perineum
- Take note of vaginal bleeding
- review fetal monitoring strip and get copy
- treat per hypotension/shock guidelines with vasopressors as last resort.
Placental abruption
premature separation of placenta after 20th week.
scant, dark bleeding until delivery.
Abd/back pain
Uterine tenderness, contractions, fetal distress, labor
May or may not cause bleeding.
Placenta previa
placenta over cervical os
painless vaginal bleeding in second or third trimester, “warning” hemorrhages over days/weeks.
Soft, pain free uterus.
contractions may or may not be present
fetal distress not usually present
Transfusion in pregnancy
Ongoing hemorrhage with loss of 1500ml or more, with tachycardia and hypotension.
Tocolytics in vaginal bleeding
controversial
consult with sending/receiving physician prior to magnesium.
Do not administer tocolytic to actively bleeding patient.
Uterine rupture
Possible bleeding
Abd pain with n/v
Diffuse abd tenderness, sudden cessation of labor
Oxytocin for uncomplicated delivery
20units in 1000ml
Run 500ml WO
then 100ml/hr
How long to wait for placenta to deliver
30 minutes
Do not pull on cord to deliver placenta.
Nuchal cord
- slip finger around infants neck and feel, slip over head if loose.
- if wrapped tightly, clamp in two places, cut and unwind
make sure anterior shoulder is delivered before cutting.
**consider twins
Prolapsed cord
- supplemental oxygen
- frequent FHT checks
- Knee/chest trendelenberg
- elevation to presenting part with hand in vagina
- if FHR <140 further elevation
- prevent drying of cord
- magnesium
McRoberts maneuver
Mother’s hips and legs flexed
suprapubic pressure
gentle downward traction on infant with maternal pushing.
Shoulder dystocia
- McRoberts maneuver
- rotation of anterior shoulder forward or backward out of AP diameter of pelvis
- delivery of posterior arm by sweeping it across the fetal chest and over perineum.
Shoulder presentation
Transport immediately and make facility aware of situation
Uterine Inversion
Manual replacement:
gentle pressure and use palm of hand to push fundus upward through cervical canal
-if contracted use tocolytics
-replace with placenta in place
-oxytocin once uterus is replaced
Oxytocin in uterine inversion
40 units in 1L up to 500ml over 10 minutes to contract uterus
Vertex delivery
- maternal oxygen
- support perineum
- allow rotation without interference
- anterior shoulder then posterior
- ensure fetal airway
- clamp cord after 30 seconds
- Oxytocin
- fundal massage
Placental delivery
do NOT pull cord for placental delivery
1. wait for spontaneous delivery (up to 30 minutes)
2. if retained placenta with bleeding consult with receiving provider.
3. if no bleeding, transport
HELLP
Hemolysis, Elevated Liver, Low Platelets
1. transport in left lateral tilt
2. treat per preeclampsia guidelines
3. consider platelet transfusion, prbcs and FFP per order of sending physician
Pre-Eclampsia
Triad of hypertension, edema and proteinuria
Eclampsia
seizures in pregnancy with no other cause
Mild vs severe pre-eclampsia
Mild: BP >140/90 and >300mg protein in 24 hours
Moderate: High bp, proteinuria, oliguria, visual disturbances, n/v, pulmonary edema, HELLP, fetal growth restriction
Pre-eclampsia Assessment
- Maternal vitals
- DTRs
- Absence/presence of clonus
- FHR by doppler
- uterine activity q15
Pre eclampsia fluid
<100ml/hr (total fluid and medication infusions)
