Obstetric Emergencies Flashcards
Categories of C section
Grade I: Emergency - Immediate threat to woman or fetus
Grade II: Urgent - maternal fetal compromise which is not immediately life threatening
Grade III: Scheduled - needing early delivery but no maternal or fetal compromise
Grave IV: Elective - time to suit woman and maternity team
What constitutes Class I Emergency or Class II Urgent C sections?
NRFHR class III FHR tracings umbilical cord prolapse
Hemorrhage antepartum - placenta previa, abruptio placenta, uterine rupture, abnormal placentation, vasa previa
Hemorrhage postpartum - uterine atony, medical treatment first
Abnormal presentation
Dystocia
presentation for cord prolapse
during or after rupture of membranes
mean dilation 5cm
prompt vaginal examination when FHR changes with ROM
labor related risk factors for obstetric hemorrhage
induction of labor >24 hours prolonged 2nd stage of labor mag sulfate laceration/hematoma uterine inversion
placental and uterine risk factors for obstetric hemorrhage
placenta previa/low lying, accrete, increta, percreta placental abruption retained placenta chorioamniotis larger uterine myoma
four T’s for obstetric hemorrhage
tone
trauma (inversion)
tissue (retained tissue, invasive placenta)
thrombin
class I hemorrhage blood loss volume and maternal response
900cc asymptomatic
15% blood loss
class II hemorrhage blood loss and maternal response
1200-1500cc
20-25%
mild tachy, mild tachypnea, orthostatic hypotension, narrowing pulse pressure, decreased capillary refill
class III hemorrhage blood loss volume and maternal response
1800-2100 cc
30-35%
severe tachy, tachypnea, cool extremities, severe hypotension, confusion
class IV hemorrhage, blood loss volume and maternal response
> 2400cc 40%
oliguria, decreased LOC shock, aggressive resuscitation
risk factors for placental abruption
cocaine, smoking, HTN
premature ROM, abdominal trauma, previous abruption
advanced maternal age, advanced parity
anesthesia for abruptio placenta
2 large bore IVs, IVF non dextrose, blood products available
FHR monitoring
vaginal bleeding: airway exam, co morbidities, massive blood loss
induction meds perferred for GA for abruptio placenta
etomidate 0.3mg/kg
ketamine 0.5-1mg/kg
but avoid ketamine with uterine hypertonus
risk factors for placenta previa
previous placenta pervia, uterine surgeries including abortions, previous cs delivery
advanced maternal age, smoking hx, multiparity
male fetus
difference between placenta previa and abruptio placenta
placenta previa is painless vaginal bleeding, no uterine tenderness, mild early contractions, normal uterine resting tone
fetal M&M from placenta previa
increased incidence of prematurity
increased incidence of IUGR, fetal anemia, and congenital anomalies
what to know before implementing anesthesia for placenta previa patient
gestational age
maternal fetal condition
amount of bleeding
type of previa
placenta accreta, increta, percreta
- basal plate placenta adheres to uterine myometrium without intervening decidual layer
- placenta chorionic villi invade the myometrium
- invades through the myometrium into serosa and surrounding organs
anesthesia for acreta/increta/percreta
massive hemorrhage
large bore IVs, a-line, CVP, blood products available, cell saver
GA
Sympathectomy of regional avoided
increases risk of failed airway, aspiration, etc. must be considered
advantage of intubation in face of massive hemorrhage
regional intubation can be avoided awake for birth sympathectomy disadvantage epidural vs spinal depends on length of sx
surgical considerations for acretra, increta, placenta
possible peripaprtum hysterectomy
IR consult for embolization
intrauterine balloon tamponade
consider OB suite vs main OR
main risk factor for uterine rupture
uterine scars (increases with C/S or myomectomies)
others: oxytocin, prostaglandin, abdominal trauma, grand multiparity, fetopelvic disproportion, fetal malpresentation, macrosomia, instrument assisted vaginal delivery
s/s and treatment for uterine rupture
s/s: nonspecific, fetal bradycardia, maternal hypotension, abdominal pain, change in uterine tone and contractions
risk is to fetus, not mother
vasa previa
neonatal volume replacement in vasa previa
colloid, salt and blood balanced solution
tx for vasa previa
30 weeks - at hospital
36 elective C/S
rupture stat delivery or CS, GA if no epidural
causes of post partum hemorrhage
- uterine atony
- retained placental products
- genital tract trauma
- coagulation abnormalities
- placenta acreta
first ,second, and third line treatments for uterine atony
first line - fluids, pressors, bladder emptying, 10-20u of oxytocin IV, uterine massage
second line- transfusion, removal of retained placenta, ergot alkyloids (methergine 0.2mg iM), uterine tamponade, prostaglandins, IV PGE2 or 15 methyl plostaglandin F2 alpha (IM carboprost, hemabate)
third - invasive measures, embolization, surgical ligation, hysterectomy possible
tx for uterine inversion
relaxation for replacement of uterus
NTG 50-100 mcg or GA RSI ETT
oxytocin 20u/L after replacement
meds for hemorrhage
oxytocin 20-80 U/L iv - dilute!, causes hypotension
methergine 0.2mg IV q2-4h- AVOID in HTN or raynaud’s
hemabate, carboprost - 250mg IM avoid with asthma, renal, hepatic, CV disease, risk of diarrhea ,fever and tachy
cytotec- 800-1000mcg
Iatrogenic risk factors for cord prolapse
Obstetric manipulation, amniotomy, artificial ROM, placement of internal monitors
Maternal and fetal risk factors for cord prolapse
Maternal is multiparity
Fetal - small size/weight, abnormal presentation, abnormally long umbilical cord, multiple gestation, prematurity, abnormal placental insertion, male gender, polyhydramnios, decreased FHR
Patient history risk factors for obstetric hemorrhage
Obesity >40 BMI Multiparity, multiple gestation Fetal wt > 4000g Coagulopathy/ bleeding d/o Prior c/s uterine sx or laparaotomies Hx of OB hemorrhage
S/s of abruptio placenta
Vaginal bleeding
Abdominal pain
Uterine tenderness & hypertonus
Fetal distress/demise
Fetal effects of abruptio placenta
Less surface area available for O2 delivery
Fetal distress demise worse than previa
T or F If mild abruption of abruptio placenta, no evidence of NRFHR, vaginal delivery may be attempted
T
Goal of placenta previa
Monitor and maintain pregnancy until 37 weeks
Increased bleeding calls for CS
Treatment for uterine rupture
Laparotomy / CS under GA
Hysterectomy
