OB/GYN Emergencies

Question 1

Maternal physiological changes in pregnancy

Answer 1

increased blood volume by 50% but still anemic
decreased Vt
displacement of esophageal sphincter(leads to GERD symptoms)
BP decreases slightly in 2nd Tri; returns to normal in 3rd Tri
HR increases 10-20 bpm throughout pregnancy

Question 2

OB transport

Answer 2

left lateral recumbent position
>relieves supine hypotension
>if supine, elevate right hip to promote blood flow and Cardiac Output
ECG, Oxygen, IV, and fetal monitoring

Question 3

Fundal assessment

Answer 3

Assessing fundal height in the abdomen and where it corrilates to the pubic synthesis
>starts at week 12(it starts to displace the bladder)
>at 20 weeks the fundus should be at the umbilicus and continues to the bottom of the xyphoid process by week 36.
>between weeks 36 and 40, you will note a decrease in fundal height
>after 16 weeks, fundal height and gestation usually are around the same measurement(# in cm)

Question 4

Fetal assessment

Answer 4

Assess fetal lie: baby to mother spine(either longitudinal or transverse.
Assess fetal presentation: Cephalic or transverse
Assess fetal position:
>ROA and LOA (R/L occipitoanterior)are the most common and usually easy without complication
>ROP and LOP(R/L occpitoposterior) usually not complicated but take longer/ more low back pain
>ROT and LOT(R/L occipitotransverse) usually have complications associated with them.
Assess fetal attitude: preferred chin to chest(flexion) or extension(not good)

Question 5

Fetal station

Answer 5

refers to the fetal head in relation to the mothers pubic bone.
measured in cm from -3 to +3. Above ischial spine is negative and anything below is positive, 0 being the head right at the ischial spine. “+4 on the floor”

Question 6

1st stage of labor

Answer 6

Begins with onset of contractions and ends with complete dilation of the cervix
Effacement– thinning of the cervix
Dilation–widening of the cervix(measured in cm)

Question 7

2nd stage of labor

Answer 7

complete dilation(10cm) and ends with birth of the fetus.

Question 8

3rd stage of labor

Answer 8

begins with delivery of the fetus and ends with delivery of the placenta

Question 9

fetal monitoring

Answer 9

Fetal HR variability–reflects a healthy nervous system and cardiac responsiveness
Decreased variability–caused by
>fetal hypoxia
>prematurity(little fluctuations before 28 weeks)
>congenital heart anomalies
>fetal tachycardia
Increased variablility(Saltatory Pattern)–caused by
>fetal hypoxia
>mechanical compression of the umbilical cord

Question 10

Fetal Bradycardia

Answer 10

defined as <120 for >5-10min. Causes:
>transvers presentations
>post 40 week babies
>Prolonged cord compression
>cord prolapse
>tetanic uterine contractions
>epidural/spinal anesthesia
>maternal seizures
>vigorous vaginal exam(cord prolapse)

Question 11

Fetal Tachycardia

Answer 11

defined as >160 for >5-10min. 160-180 is mild. >180 is considered significant. >200 is likely a tachyarrythmia or congenital defect.
Causes:
>Fetal hypoxia
>maternal fever
>hyperthyroidism
>maternal or fetal anemia
>prematurity
**on the strip, distance between 2 bold lines is equal to 1min interval, and smaller boxes in between them are 10 sec intervals

Question 12

Accelerations/ Decelerations/ Variable/ Late

Answer 12

Accelerations: short bursts of 15bpm which last 15 sec. Normal presentation and are a sign of well being during labor.
Decelerations: normal finding during birth. Occurs when head is compressed by contractions and descending through the birth canal. Not harmful
Variable decelerations: generally irregular. Sharp dip that does not match the contractions. Caused by cord compression, premature rupture of membranes, or decreased amniotic fluid volume.
Late Decelerations: begins at or after peak of contraction, returns to baseline after contraction. Smooth shallow dips. Caused by issue with the placenta or uterine issue. Most worrisome!! Think fetal hypoxia

Question 13

Sinusoidal rhythm

Answer 13

very rare and VERY BAD. Requires immediate C-section
>no changes with contractions
>similar to sine wave appearance
>usually indicates fetal anemia and hypoxia
>increased morbidity and mortality for mother and fetus

Question 14

Management of fetal distress

Answer 14

Oxygen
IV fluids
Lateral positioning
Rule out cord prolapse(pulsating mass in vagina)
Modify pushing efforts(push with q other or q 2 contractions)
Hypertonic or tetanic contractions occuring? discontinue Oxytocin

Question 15

Preterm labor

Answer 15

Regular contractions causing changes to the cervix that occur between 20-37 weeks. Signs:
>Change or increase in vaginal discharge
>plevic pressure
>constant low, dull backache
>ruptured membranes
Expected Tx/meds: Corticosteroids, Mag, Tocolytics, and antibiotics

Question 16

Premature ruptured membranes

Answer 16

Amniotic membrane rupture before labor onset(usually 1hr or more)
Greater risks to the fetus:
>Infection
>Preterm delivery
>Umbilical cord compression
>Umbilical cord prolapse

Question 17

Imminent Delivery

Answer 17

> Regular contractions 1-2 min apart
bloody show
urge to bear down(feeling BM)
crowning of the baby
mother says its coming

Question 18

Pregnancy induced HTN(PIH)

Answer 18

AKA: Gestational HTN
HTN in pregnancy is always abnormal(>140/90) Other signs:
>Abnormal weight gain
>HA
>Visual disturbances
>Generalized edema
>Oliguria
>Does NOT present with proteinuria

Question 19

PIH Tx

Answer 19

> IV Hydralazine or Labetalol, or PO Nifedipine(don’t use CCB w/Mag)
Goal is DBP<100-105 and SBP<160mmHg
Watch for late decelerations and poor variability
Monitor fetal movement
Monitor for preeclampsia/eclampsia

Question 20

Preeclampsia and Eclampsia

Answer 20

Symptoms: HTN, Proteinuria, and excess weight gain with edema(Eclampsia includes seizure activity)
Tx: is aimed at decreasing BP, seizure prevention, and preventing deterioration of fetal well-being
Meds: Hydralazine and Labetalol for HTN.
Mag(first line!!), Valium or Ativan for seizures.

Question 21

HELLP Syndrome

Answer 21

(Hemolysis, Elevated Liver enzymes, Low Platelets)
LAbs: Increased AST and ALT. Platelets <100K
Thought to be severe complication of severe preeclampsia, might be its own thing now. Not Sure*
Signs: RUQ/Epigastric pain, HA, N/V, DBP >100, and myalgia
Tx: immediate delivery in most circumstances

Question 22

Placentia Previa

Answer 22

Painless bright red bleeding
Placenta attached over the opening of the cervix
Tx: high flow O2, replace volume, tocolytics and blood products, assess for contractions, fetal movement, Fetal heart tones(FHT) hemorrhage. Avoid vaginal exams!!! will increase risk of bleeding
requires immediate C-section

Question 23

Placenta Abruption

Answer 23

Premature separation of the placenta from the uterine wall
Fetus at risk for hypoxia and death
Painful/tender rigid abdomen with dark red vaginal bleeding
Increased risk for hypovolemic shock, DIC and death in the mother

Question 24

Uterine Rupture

Answer 24

May be misdiagnosed as placental adruptiob
Watch fundal height
*Look for previous C-section scar. Common if C-section occured in the past. Also feel for fetal limbs/head protruding through uterus.
Tx: Fluid resusciation, blood products, Oxytocin, and Delivery

Question 25

Nuchal cord

Answer 25

Variable decelerations are common
Gently loosen and draw down over the head
Somersault maneuver
Clamp cord and cut before the shoulders are delivered if too tight too remove

Question 26

Prolapsed Cord

Answer 26

Umbilical cord presents through the birth canal before delivery of the head
Causes cord compression and increased likelihood of fetal death
Elevate pelvis(steep trendelenburg or knee to chest)
Place gloved hand into vagina to relieve pressure off the cord
DO NOT PUSH!! Mom needs a C-section
Manual pressure on the fetus if pulse is not felt in the cord or reposition
High O2

Question 27

Breech presentation

Answer 27

Frank=butt, Complete= both legs, Footling=limb(1)
Fetus should not be touched until umbilicus has spontaneously delivered
Palpate cord for feta heart rate(FHR)
After shoulders deliver, rotate trunk so back is anterior and apply downward pressure
Apply suprapubic pressure to deliver the head(Mauriceu’s maneuver)

Question 28

Postpartum Hemorrhage

Answer 28

Blood loss >500mL in vaginal delivery or >1L in C-section
Common causes:
>Uterine atony
>Retained placenta
>Trauma related to delivery

Question 29

Postpartum Hemorrhage Tx

Answer 29

> Fluid bolus
External uterine massage
Oxytocin
Methergine, Cytotec
Blood products
Bimanual uterine compression(squish uterus from inside and out)

Question 30

Uterine Inversion

Answer 30

Uterine fundus pulled inferiorly into the uterine cavity
Tx:
Put it back in(Johnson maneuver), fluid bolus, DO NOT remove the placenta, and stop uterotonic meds(Oxytocin). Myometrial relaxation(tocolysis) Meds for that are Mag and IV NTG. Blood products.
IF you can’t replace the uterus, cover with moist towel and prevent it drying out

Question 31

Signs of toxic levels of Mag in the patient after seizure prevention Tx

Answer 31

Absent deep tendon reflexes(DTR)