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OB/GYN Emergencies Flashcards

1
Q

Maternal Physiological Changes

A

Increased circulatory blood volume (50%)
…“anemia of pregnancy”

Decreased tidal volume

Esophageal sphincter displaced (GERD)

BP decreases slightly in 2nd trimester; returns to normal in 3rd trimester.

HR increases 10-20 bpm throughout pregnancy

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2
Q

OB transport

A

Gravida:
number of pregnancies

Para:
number of live births

Abortions:
before 20 weeks

Gestational age
how many weeks (if known)

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3
Q

Inferior vena cava (pregnancy)

A

Transport in lateral recumbent position.
…relieves supine hypotension
…If supine, elevate right hip
…prevents compression of inferior vena cava

ECG monitoring
Oxygen
Fetal monitoring
IV access

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4
Q

Fetal assessment

A

Assess fundal height
From symphysis pubis to top of fundus
~12 weeks should be at umbilicus

Assess fetal lie - baby’s position in mother

Assess presentation
Cephalic (vertical, head down)/transverse (breach, shoulder = more difficult birth)

Assess position (facing front vs back)

Assess attitude

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5
Q

Fetal positions

A

ROA and LOA most common, fewest complications
Right/left occipitoanterior

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6
Q

Fetal heart tones

A

Usually audible with doppler by 8-12 weeks

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7
Q

Fetal station

A

Refers to fetal head position in relation to mother’s pubic bone.

Measured in CM from -3 to +3

“+4 on the floor” - baby is coming out

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8
Q

Stages of Labor (1)

A

Begins with onset of contractions and ends with complete dilation of cervix.

Effacement: thinning of the cervix (0-100%)

Dilation: Widening of the cervix (0-10cm)

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9
Q

Stages of Labor (2)

A

Begins with complete dilation of cervix and ends with birth of fetus

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10
Q

Stages of labor (3)

A

Birth to placental delivery

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11
Q

Fetal monitoring

A

FHR variability - reflects a health nervous system and cardiac responsiveness
…typically 5-10 bpm

Decreased variability:
Fetal hypoxia
Prematurity (little fluctuation before 32 weeks)
Congenital heart abnormalities

Increased variability:
Fetal hypoxia
Mechanical compression of umbilical cord

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12
Q

Fetal monitoring (Bradycardia)

A

Bradycardia: FHR <120 for 5-10 min

Causes: prolonged cord compression
Cord prolapse
titanic uterine contractions
Epidural/spinal anesthesia
Maternal seizures

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13
Q

Fetal monitoring (tachycardia)

A

Tachycardia: >160 for 5-10 minutes

Causes:
fetal hypoxia
Maternal fever
hyperthyroidism
maternal or fetal anemia
prematurity

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14
Q

Fetal monitoring (accelerations)

A

Signs of well-being during labor

Increase of 15bpm which lasts 15 seconds

Caused often by stimulation (ie palpation), contractions, loud noises, etc

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15
Q

Fetal monitoring (early decelerations)

A

Occurs when the baby’s head is compressed

Descending through birth canal

Compression of head in birth canal causes vagal stimulation and therefore slowed HR

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16
Q

Fetal monitoring (variable decelerations)

A

Generally irregular

Due to cord compression occluding umbilical vein.
…premature rupture of membranes
…decreased amniotic fluid volume

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17
Q

Fetal monitoring (late decelerations)

A

Worrisome form of HR pattern
Signifies reduced O2 supply to fetus
Longer HR drop

Begins after peak of contraction
Returns to baseline after contraction has ended

Causes: maternal hypotension, preeclampsia, post-due date fetus

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18
Q

Fetal monitoring (sinusoidal)

A

Rare. Worst case scenario

No changes in fetal HR with contractions
Similar to sine wave appearance
Usually indicates fetal anemia or hypoxia

VERY BAD…fetus needs to be delivered

Administer oxygen via NRB
IV fluid bolus
hypertonic or titanic contractions (rapid, back to back contractions) - discontinue oxytocin. Try to push only every other contraction.
Rule out cord prolapse
Lateral positioning

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19
Q

Preterm labor

A

20-37 weeks gestation
Regular contractions causing changes to cervix.

Signs:
Change or increase in vaginal discharge
Pelvic pressure, low backache

Triggers:
Infections (ie UTI), stress, poor nutrition, twins, drugs alcohol, smoking

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20
Q

Preterm labor complications

A

Respiratory distress
Sepsis
Intraventricular hemorrhage
Impaired neurodevelopment outcomes

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21
Q

Preterm labor treatment

A

Administered between 22 and 34 weeks gestation

Tocolytics:
Calcium channel blockers
beta-adrenergic receptor agonists
magnesium
NSAIDS
Corticosteroids and antibiotics

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22
Q

Tocolytic contraindications

A

Intrauterine fetal demise
lethal fetal anomalies
severe preeclampsia/eclampsia
Maternal bleeding with hemodynamic instability
intraamniotic infection
specific drug contraindications

23
Q

Tocolitics (nifedipine)

A

may be better choice in pregnancy due to better neonatal outcomes.

Used more often in pts with >32 weeks gestation

Contraindications:
known drug sensitivity
Hyoptension
Cardiac lesion

24
Q

Signs of magnesium toxicity (in pregnancy)

A

…Absent deep tendon reflexes

25
tocolytics (Indomethacin)
most common in pts <32 wks gestation Increased risk of gastric ulcer formation and GIB Contraindications: maternal platelet dysfunction hepatic dysfunction renal dysfunction hypersensitivity to aspirin
26
tocolytics (terbutaline)
Beta-adrenergic receptor agonist off-label use for preterm labor FDA warning against prolonged use in management of preterm labor Contraindications: tachycardia poorly controlled hyperthyroidism or diabetes
27
tocolytic
a medication that stops or slows uterine contractions during pregnancy.
28
tocolytics (magnesium sulfate)
Weak tocolytic effects used for neuroprotection of fetus monitoring of mother is essential antidote is calcium gluconate Contraindications: pt hx of myasthenia graves Pts with cardiac compromise ...mag sulfate in conjunction with CCBs can suppress muscular contractility, resulting in respiratory distress
29
tocolytics (nitroglycerine)
questionable tocolytic efficacy Smooth muscle relaxation can lead to maternal hypotension Contraindications: hypotension
30
Corticosteroids in pregnancy
Used to boost development of fetal lung, brain, and digestive systems Can reduce risk of intraventricular hemorrhage Betamethasone
31
Antibiotics in pregnancy
Used to prevent group b-strep Goal is to prevent secondary infections Has no direct effect on symptoms associated with preterm labor.
32
Premature rupture of membranes
Premature amniotic membrane rupture, usually before labor onset Before 37 weeks gestation is considered preterm (PPROM) Greater risks to the fetus: infection preterm delivery umbilical cord compression umbilical cord prolapse
33
Imminent delivery
Regular contractions 1-2 minutes apart bloody show urge to bear down (feeling of needing to have a BM Crowning Mother says "it's coming!"
34
pregnancy induced hypertension (aka gestational hypertension)
>140/90 Signs: abnormal weight gain headaches visual disturbances generalized edema oliguria does not present with proteinuria
35
PIH treatment
pregnancy induced hypertension Hydralazine IV, labetalol IV, or oral nifedipine Goal is DBP <100-105 and SBP < 160 watch for late decelerations and poor variability monitor fetal movement monitor for preeclampsia/eclampsia
36
Preeclampsia
Typically dx after 20 wks gestation and < 4 weeks post-partum Systolic bp > 140; diastolic >90 in previously normotensive mothers Systolic > 160; diastolic > 110 need emergent treatment Common presentations: hypertension, proteinuria
37
preeclampsia treatment
aimed at decreasing bp, preventing seizures, preventing further deterioration of fetal well-being. hydralazine, labetelol magnesium sulfate (sz prophylaxis) valium or Ativan
38
eclampsia
Typically dx after 20 weeks gestation and < 4wks postpartum Systolic bp > 140; diastolic >90 in previously normotensive mothers Systolic > 160; diastolic > 110 need emergent treatment COmmon presentations SEIZURES (differentiates eclampsia from preeclampsia hypertension, proteinuria, excessive weight gain with edema
39
Eclampsia tx
*delivery of fetus* Manage seizures ...mag sulfate, consider benzos BP control hydralazine labetalol
40
H.E.L.L.P. Syndrome
Hemolysis, Elevated Liver enzymes, Low Platelets Generally a 3rd trimester problem Thought to be severe complication of preeclampsia - can be standalone RUQ/epigastgric pain, headache, nausea, DBP >100, myalgia Treatment consists of immediate delivery of baby if >34 weeks gestation
41
Placenta previa
Placental attachment over cervix opening Painless bright red bleeding Most mothers with prenatal care will be aware of this Reduce stimulation/movement Will require c-section
42
Placenta previa treatment
High-flow O2 Replace volume Assess for contractions, fetal movement, FHT, hemorrhage Tocolytics and blood products vaginal exams are deferred
43
Placental abruption
Premature separation of placenta from uterine wall Fetus at risk for hypoxia and death Uterine tenderness, board-like abdomen, vaginal bleeding (may be dark red) Volume of bleeding may not be an accurate representation of severity of abruption. Increased risk of hypovolemic shock, DIC and death
44
uterine rupture
spontaneous tearing of uterus May be misdiagnosed as placental abruption Look for signs of previous cesarean ...rupture can occur along cesarean scar Watch fundal height Fluid resuscitation Blood administration oxytocin delivery of fetus Tx: supportive care fluid resuscitation, blood products emergent delivery
45
Nuchal cord
movement of fetus through loop of umbilical cord Variable decelerations gently loosen and draw down over head Somersault maneuver Clamp cord and cut before shoulder are delivered if too tight to remove
46
Prolapsed cord
umbilical cord presents through birth canal before delivery of the head Causes cord compression Elevate pelvis of mother ...Steep trendelenburg or knee-chest DO NOT PUSH THE CORD BACK IN Tell mom not to push manual pressure The person who decompresses the cord must maintain that position until pt in OR high-flow O2
47
Breech presentation
More common in preterm higher risk of complications Frank breech - butt first. Most common Complete breech - butt first with hips/knees flexed. Footling breech - feet first
48
Postpartum hemorrhage
Blood loss >500 mL in vaginal delivery or >1000 mL in c-section Common causes (4 T's): tone: uterine atony, boggy uterus trauma: Genital tract tears tissue: retained placental tissue thrombosis: coagulopathy
49
Postpartum hemorrhage treatment
Fluid boluses external uterine massage oxytocin for uterine atony blood products bimanual uterine compression
50
Delivery of placenta
Typically within 20 minutes of fetus Don't pull on it!
51
Uterine inversion
Uterine fundus pulled inferiorly through the uterine cavity Treatment: fluid boluses DO NOT remove the placenta Stope uterotonic medications
52
Uterine inversion treatment
Immediate manual reduction ...Johnson maneuver Myometrial relaxation (tocolysis ...Mag sulfate ...IV NTG Blood products
53
Anaphylactoid syndrome
Antibody response to amniotic fluid and fetal components entering maternal circulation Endogenous mediators are released Maternal response: hypoxia, hemodynamic instability, and/or consumptive coagulopathy...exsanguination Fetal response: respiratory acidosis, bradycardia, neurological injury
54
anaphylactoid syndrome treatment
Needs to be immediate Supportive therapy high flow O2 intubated as needed PEEP as needed fluid resuscitation Hemodynamic monitoring Administer PRBCs, FFP Corticosteroids and epinephrine Prepare for emergent postmortem c-section

CFRN (18 decks)

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