OBGYN Emergencies 2

Question 1

FETAL HEART MONITORING

1. Normal fetal HR?
2. Look for?
3. Decelerations where HB drops?
4. Lack of variability or prolonged
   - Over what?
   - HR under what indicated fetal distress?
5. “Late” decelerations indicate?
6. “Sinusoidal” pattern indicates?

Answer 1

1. Normal fetal heart rate 120-160beats/min
2. Look for “variability” & accelerations
3. OK to decrease slightly during a contraction & then return to normal
4. Lack of variability or prolonged (> 10 min.) HR< 120 indicates fetal distress
5. “Late” decelerations indicate fetal distress
6. “Sinusoidal” pattern indicates severe fetal distress

Question 2

What is this?

Answer 2

NORMAL FETAL HEART TRACING

Question 3

What is this?

Answer 3

Normal baseline HR

There is not a decelration with every contraction

Variable decelerations

Usually occurs because of cord compression

Question 4

What is this?

Answer 4

Decelerations come after contractions

LATE DECELERATIONS

Loss of variability

Lower oxygen and maybe starting towards acidosis

Question 5

What is this?

Answer 5

Get to bed and C section in 20 minutes

Question 6

What is this?

Answer 6

Baby needs to be delivered immediately

Question 7

FETAL HEART TRACINGS—FETAL DISTRESS

1. Initial measures are trying to increase O2 to the fetus: 3
2. Stop what meds? If continued frequent contractions w/ continued fetal distress may consider what?
3. If fetal distress continues for 15 – 20 minutes may try what?
4. If this does not work?

Answer 7

1.

• Maternal administration of O2
• Change maternal position
• Bolus w/ normal saline
  2. Stop any utertonic drugs and if continued frequent contractions w/ continued fetal distress may consider tocolytic
  3. Iscalp stimulation to see if FHR will accelerate which is reassuring—
  4. if the FHR does NOT accelerate can indicate fetal acidosis and prompt delivery is indicated

Question 8

MILD PREECLAMSIA

1. definition? 2
2. DDx? 8

Answer 8

1. Definition:
   - 2 BP measurements 6 hrs apart >140/90
   - + Proteinurea >0.1 g/L on urine dipstick or > 300 mg protein 24 hrs.
2. DDx:
   - DKA
   - Gallbladder disease
   - Glomerular nephritis
   - Hepatic encephalopathy
   - TTP
   - PUD
   - Viral hepatitis
   - Nephrolithiasis

Question 9

MANAGEMENT OF MILD PREECLAMPSIA

1. Tx? 2
2. Labs?3
3. Assessment of fetus? 3
4. Any sign of severe preeclampsia?

Answer 9

1.

• If patient is >/= 37 weeks—deliver
• 34-36 weeks can do expectant management**
  2. Labs:
• CBC w/ platelets,
• CMP (check Cr),
• 24 hour urine
  3. Assessment of fetus:
• US to assess size,
• amount of amniotic fluid
• Nonstress test (?)
  4. Any sign of severe preeclampsia—DELIVER!

Question 10

SEVERE PREECLAMPSIA

1. Definition?
2. Management? 4
3. If less than 30 wks best to?

Answer 10

1. Definition:
   - SBP > 160, DBP >110
   - Proteinurea >/= 5 gm in 24 hours
   - Signs of end organ damage**

2.

• Indication for admission
• Start on magnesium sulfate (to prevent?)
• Treat BP with- hydralazine, methyldopa
• Delivery—induction initially may require c-section
  3. go to a tertiary center for management w/ a perinatologist

Question 11

MAGNESIUM SULFATE

1. Maintenance phase given only after what?
2. What are signs that magnesium level is OK? 2
3. SE: with loading dose? 5
4. Fetus: SE?

Answer 11

1. patellar reflex is present, loss of reflexes first sign of hypermagnesemia

2.

• Respirations >12 per min &
• urine out>100cc/hr

3.

• diaphoresis,
• flushing because of vasodilation & decrease in BP,
• N&V,
• rare pulmonary edema and
• chest pain
  4. no significant SE

Question 12

MORE ON MANAGEMENT

1. Mag sulfate acts as what?
2. The cure for preeclampsia is?
3. The patient is still at risk for complications including seizures for how long postpartum so mag sulphate should be continued & the patient monitored closely?

Answer 12

1. Magnesium sulphate acts as an anticonvulsant
2. The “cure” for preeclampsia is delivery of the placenta
3. 48-72 hrs.

Question 13

ECCLAPMSIA

1. What is it?
2. Gernerally lasts how long?
3. management? 5

Answer 13

1. The occurrence of 1 or more general tonic-clonic seizures or coma in a preeclamptic woman**
2. Generally last no longer then 3-4 minutes (usually 60-75 sec.)
3. Management:
   - Protect maternal airway
   - Lower blood pressure if severely high
   - Prevent further seizures by starting: Mag sulfate
   - Persistent seizures—lorazepam or diazepam
   - Monitor fetus—often limited bradycardia**

Question 14

Blood pressure meds to use in ecclampsia? 2

Answer 14

• Hydralazine
• Labetolol

Question 15

DEATH IN UTERO

1. Presentation?
2. Document? 2
3. Management in 2nd and 3rd trimester?
4. What are they at risk for if they baby remains in the uterus?

Answer 15

1. Presentation: usually the mother comes in c/o decreased fetal movement
2. Document: no fetal heart sounds and NO cardiac activity on ultrasound
3. In 2nd and 3rd trimester generally best to induce labor except if prior c-section then the woman is at higher risk of uterine rupture**
4. Mother is at risk of coagulopathy the longer the fetus remains in the uterus

This is a great loss and should be treated as such—attend to emotional needs of the parents

Question 16

BREECH DELIVERY

Steps if unable to do a C section

7

Answer 16

1. CONTROL DELIVERY-REACH BRING OUT ONE LEG
2. ONE LEG OUT
3. TORSO DELIVERED
4. DELIVERY OF LEFT ARM
5. RIGHT ARM DELIVERED
6. It is important to keep the head flexed, inserting a finger into the baby’s mouth can aid this!
7. Suprapubic pressure may also be applied to keep head flexed

Question 17

SHOULDER DYSTOCIA MANEUVERS

6

Answer 17

1. A distended bladder if present is drained
2. McRoberts: two assistants sharply flex the maternal thighs back against the abdomen
3. Apply suprapubic pressure with palm or fist**
4. Cut a generous episiotomy
5. Rubin maneuver: clinician places one hand in vagina behind poterior shoulder rotates it anterior toward fetal face
6. Get mom on “all fours”

Question 18

Describe the following:

1. Gaskin all-fours?
2. Symphysiotomy?

Answer 18

1. Gaskin all-fours: place the mother her hands & knees down and the infant is delivered by gentle downward traction on the post shoulder
2. Symphysiotomy: used as last resort when c-section not available, anesthetize area, displace urethra with finger & cut through cartilagenous portion of symphysis

Can replace fetal head and do emergent c-section

Question 19

EXTREMITY PRESENTATION

May be a vertical or breech presentation with an extremity beside it:

1. Do not use what in these cases?
2. Sometimes the extremity will naturally be moved out of the way and what can happen?
3. If the extremity persists then what?
4. May be what kind of breech or leg first or arm. How are these generally delivered?

Answer 19

1. DO NOT use oxytocin in these cases
2. Sometimes the extremity will naturally be moved out of the way and a vaginal delivery will occur
3. If the extremity persists—c-section needs to be done
4. May be a footling breech or leg first or arm generally these are delivered by c-section unless they spontaneously deliver **

Question 20

ACUTE HERPES VULVOVAGINITIS

1. The highest risk for a newborn to acquire congenital herpes is how?
2. For any pregnant woman who is in labor who has a history of genital herpes she should have a c-section if? 2

Answer 20

1. The highest risk for a newborn to acquire congenital herpes is to a mother who was infected with primary HSV-2 during the pregnancy
2. For any pregnant woman who is in labor who has a history of genital herpes she should have a c-section if:
   - She has active herpes lesions on or near the birth canal
   - Any prodromal symptoms on or near the birth canal