Obstetrical Emergencies Flashcards
Shoulder Dystocia
- Failure of fetal shoulders to deliver spontaneously
- Can be catastrophic
- Unpredictable and unpreventable
Should Dystocia Diagnosis
- Turtle sign
- Head delivers, remainder does not
Shoulder Dystocia Pathophysiology
- Size discrepency b/w fetal shoulders and maternal pelvic inlet
- Due to:
*macrosomia
*large chest relative to BPD
*absence of truncal rotation
+shoulders should be oblique (internal rotation fetal head)
*shoulders remain A-P
Shoulder Dystocia Risk Factors
Antepartum
- Macrosomia (>4500g)
- DM/GDM (increases overal risk by 70%)
- Muliparity
Intrapartum
- Prolonged deceleration phase of labor
- Prolonged 2nd stage
- Protracted descent
- Operative delivery (vacuum>forceps)
No evidence based data risk factors for shoulder dystocia
- Male
- AMA (advanced maternal age)
- Short maternal stature
- Abnormal pelvic shape/size
Unpredictability of Should Dystocia
- 25-50% have no defined risk factor
- 50% occur in infants birth weight <4000g
- 84% did not have prenatal dx macrosomia by US
- 82% infants w/ brachial plexus palsy did not have macrosomia
Fetal Macrosomia defintion
- Birth weight of >8lbs, 13oz (4,000grams), regardless of his or her gestational age
Fetal Macrosomia ris factors to fetus during delivery
- Shoulder dystocia/birth trauma
- Brachial plexus injury (C5, C6, Erb-Duchenee paralysis, Klumpke’s palsy)
- Asphyxia/cord compression
- Fracture humerus or clavicle
Klumpke palsy
- Lower plexus injury to the lower roots of the brachial plexus
- Involving C8 and T11 roots
- There is loss of grasp reflex. The hand is supinated, the wrist extended, and the fingers clawed
Time frame during delivery before neonatal asphyxia and/or cortical injury
- 7min.
Should Dystocia Treatment
In order of importance:
- Recognition
- Notify nurses, call for help
- McRoberts maneuver (first maneuver that should be performed)
- Suprapubic pressure
- Consider episiotomy if you need more room to perform maneuvers or tissue dystocia
- Delivery of posterior arm
- Wood’s screw
- Rubin’s maneuver
- Gaskin
- Fracture of clavicle
- Zavanelli maneuver
- Abdominal rescure
- Symphysiotomy
McRobert’s Maneuver
- 42% success rate
- Pelvic inlet and outlet have more vertical alignment
- Flattens sacrum
- Cephalad rotation of pubic symphysis
- Elevates anterior shoulder and felxes fetal spine
- McRobert’s Plus Suprapubic pressure = 54-58% success rate
Woods Screw
- Maneuver to help w/ shoulder dystocia
- Fingers of first hand remain behind anterior shoulder (Rubin II). OB inserts fingers of second hand in front (chest side) of the posterior shoulder
- Apply pressure as in Rubin II in combination w/ pressure to front of posterior shoulder to rotate into the oblique. If delivery is not achieved, continue rotation thru 180 degress if able
- Attempt delivery
Rubin II Maneuver
- Maneuver to help w/ shoulder dystocia
- Assistant applies downward pressure “CPR” style above pubic symphysis (Rubin I)
- OB inserts fingers of one hand into vagina and applies pressure behind anterior should so anterior should displaced toward fetal chest
- Once shoulders in oblique diameter, attempt delivery
- McRoberts maneuver may be applied throughout
Zavanelli Maneuver
- Last resort techique during delivery
- Fetal head returned to pre-restitution position and slowly replaced in vagina w/ steady upward pressure for delivery by C-section
HELPER Algorithm
Steps taken during shoulder dystocia
- H: Call for Help; should dystocia is called if shoulders cannot be delivered w/ gentle traction
- E: Evaluate for Episiotomy: not routinely indicated; maybe needed when attempting intra-vaginal maneuver
- L: Legs (McRoberts): hyperflexion and abduction of hips- initial maneuver
- P (Suprapubic Pressure): no fundal pressure; combination of McRoberts and suprapubic pressure resolves most shoulder dystocias
- Enter (Internal Maneuvers): Wood’s, Rubin’s
- Remove: Delivery posterior arm
On expulsion of the head, a shoulder dystocia is recognized. Before instituing maneuvers the next step is to:
A) Tell the pt not to push
B) Apply fundal pressure
C) Increase or initate Oxytocin administration
D) Cut a large episiotomy
Answer: Tell the pt not to push
- Initially it is best to do nother that will further impact the anterior shoulder above the pubic symphysis. The Simplest way to avoid further impaction is to ask the pt. to stop pushing (its bone against bone right now and show pushing further is not going to help)
Shoulder Dystocia Prophylactic Cesarean Indication
- Not recommended by ACOG
- Exceptions:
*>5000g in mother w/o DM
*>4500g in mother w/ DM
2nd and 3rd trimester bleeding dDx
- Placenta previa
- Abruptio placenta
- Vasa previa
- Placental implantation issues (accreta/increta,percreta)
- Uterine rupture
- Preterm labor
- “Bloody show” assoc. w/ cervical insufficiency or labor
Bleeding during pregnancy risk factors
- Multiparity
- Pevious previa
- Increaseing maternal age
- Uterine curettage
- C-section
- Prior cesarean section/uterine scar
- Uterine surgery
- Chronic hypertension
- Smoking
- Multiple gestation
- Cocaine use
Placenta Previa
- Placenta is located over or near the internal os of cervix
- Categorized into 4 types:
*complete: placenta completely covers internal os
*partial: placenta partially covers internal os
*marginal: placenta just reaches internal os, but does not cover it
*low-lying placenta: placenta extends into lower uterine segment but does not reach internal os
Placenta previa potential consequences
- Antepartum bleeding
- Need for hysterectomy
- Placenta accreta
- Intrapartum/postpartum hemorrhage
- Need for blood transfusion
- Preterm delivery
Placenta Previa Diagnosis
- Screen w/ abdominal u/s, however true diagnosis is made w/ transvaginal u/s
*may see a false pos. if bladder is full
- Presents as painless vaginal bleeding
*w/ dilation of the internal os, placenta begins to separate and causes bleeding
- Perform speculum exam instead of digital exam…NO VAGINAL EXAMS!!!
Placenta Previa Prophylactic Treatment
- Pelvic rest (nothing to be inserted in vagina)
*from diagnosis vs beginning of 3rd trimester
- Cesarean delivery at 36-37wks
*want to take mother to delivery a little earlier so that she doesnt go into labor and begin dilating
Placenta Previa Treatment w/ Acitve Bleeding
- Consider monitoring as inpatient
- If stable, can continue to monitor
- If unstable, consider delivery
Placental Abruption
- Premature separation of the placenta
*can be partial or complete
- Bleeding occurs b/w membranes and decidua basalis
- Hemorrhage can be concealed or external
Placental Abruption Risk Factors
- Prior abruption
- Smoking
- Trauma
- Cocaine use
- Multifetal gestation
- HTN/preeclampsia
- Thrombophilias
- Advanced maternal age
- PPROM
- Chorioamnionitis
- Polyhydramnios
- Advanced parity
- Myomas
Clinical Presentation of Abruption
- PAINFUL vaginal bleeding
- Abdominal pain/uterine tenderness
- Uterine contractions/irritability
- May see fetal distress: late deceleration, bradycardia, tachycardia
Placental Abruption Evaluation
- Rule out previa first
*abdominal u/s to examine placental location
*U/S may show a retroplacental collection of blood if abruption is significant, however u/s does not r/o abruption
- EFM to eval fetal status
- Look for cause, treat underlying cause
- Labs
*K-B
*CBC
*blood type and screen (consider type and cross)
*coags: PT/INR, fibrinogen
Placental Abruption Treatment
- Depends on maternal/fetal condition
- IV fluids
- O2
- Transfusion of blood products
- Deliver for fetal or maternal indications
*nonreassuring fetal status
*maternal hemorrhage, DIC, etc.
Fetal and Maternal complications w/ abruptions
Maternal
- Anemia
- Hemorrhagic shock
- DIC
- Death
Fetal
- Hypoxia
- Anemia
- Intrauterine growth restriction
- Death
Vasa Previa
- Condition in which babies’ blood vessels cross or run near the internal opening of the uterus. These vessels are at risk of rupture when the supporting membranes rupture, as they are unsupported by the umbilical cord or placental tissue
- 1/5,200 pregnancies
- Increased risk w/ IVF
- Contraindication to AROM
Placental Implantation Issues
- Placenta that is abnormally adherent to the uterus
- May lead to massive hemorrhage resulting in DIC, need for hysterectomy, injury to other organs, and death
*avg blood loss in delivery is 3-5L
- Delivery by cesarean section at 34-35wks or earlier if pt presents w/ hemorrhage
- Most likely requires hysterectomy at time of delivery
- Types:
*placenta accreta
*placenta increta
*placenta percreta
Placenta Accreta
- Placenta invades uterine lining too deeply
Placenta Increta
- Placenta invades the myometrium
Placenta Percreta
- Placenta invades thru the myometrium and serosa, sometimes into adjacent organs (bladder, bowel)
Uterine Rupture
- Full thickness disruption and separation of uterine wall, including overlying visceral peritoneum
*uterine dehiscence (aka “window”) is disruption and separation of uterine scar, but visceral peritoneum remains intact
- Develops as a result of preexisting injury, anomaly, or trauma of uterus
- Most common cause is separation of previous cesarean scar
*most commonly from a classical incision
Consequences of Rupture
- Protrusion or expulsion of fetus or placenta into abdominal cavity causing fetal distress
*may see recurrent variable decelerations on EFM
- Clinically significant uterine bleeding causing need for blood transfusion and potentially hysterectomy
- Fetal mortality is 7%
- Maternal mortality is <1%
Treatment for uterine rupture
- Immediate cesarean
- IVF and blood products as needed
- Neonatal resuscitation
- Uterine repair and potential for hysterectomy
Primary (Early or Acute) Post-partum hemorrhage
- Delivery to <24h PP
- 90% PPH cases
- Assoc. w/ more bleeding
Secondary (Late) Post-partum hemorrhage
- 24h-12wks postpartum
- Affects 1-3% all deliveries
- Common causes:
*infectino
*retained products
*abnormal uterine involution
Post-partum hemorrhage epidemiology
- Top 5 causes maternal mortality
- # 1 cause maternal mortality worldwide
- Developed countries 1/100,000 births vs 1/1000 births in developing countries
- Incidence 5-10% deliveries
*depends on definition used
Physiologic Adaptations of Pregnancy
- Plasma volum 40-50% increase
- RBC 20-30% increase
- Cardiac output 40% increase
- Fibrinogen and factor VIII increase
Blood Loss Signs and Symptoms Chart
5 T’s of Post-partum hemorrhage etiologies
- Tone (uterine atony)
- Tissue (retained products)
- Trauma (laceration)
- Thrombin (coagulopathies)
- Traction (uterine inversion)
Uterine Atony
- Serious condition that can occur after childbirth. It occurs when the uterus fails to contract after the delivery of the baby, and it can lead to a potentially life-threatening condition known as postpartum hemorrhage
- 75-90% PPH…mostly primary PPH
- 6% after C-section
- Risk factors after C-section
*multiples
*hispanic
*induced or augmented labor
*macrosomia
*chorioamnionitis
Other Causes (aside from uterine atony) that cause PPH
- Retained placenta or membranes
*includes placenta accreta
- Coagulation disorders/defects
*Von Willebrand’s disease
- Uterine inversion
- Subinvolution of placental site
- Laceration of genital tract
*including lower uterine segment
PPH Risk Factors
- Prolonged or rapid labor
- Augmented labor
- History of PPH
- Episiotomy
- Operative delivery
- Chorioamnionitis
- Preeclampsia
- Overdistended uterus
*twins
*polyhydramnios
*macrosomia
PPH Treatment Steps
- Initial Assessment
Examine perineum, vagina, and cervix to look for lacerations and explore the uterine cavity for retained products of conception or lochia block
- Repair with absorbable suture
- May need seation or to go to the OR
- Check uterine fundus to examine for uterine atony, if atony present:
*Perform uterine massage
*Administer uterotonic medication
+oxytocin
+methergine
+prostaglandins (hemabate, misoprostol)
- Directed therapy
- Intractable PPH
- Surgery
- Post Hysterectomy Bleeding
Utertonic Medications
- Oxytocin (Pitocin)
- Ergot (Methergine)
- Prostaglandins
*hemabate
*misoprostol
- Vasopressin
Oxytocin (Pitocin) Contraindications
- Hypersensitivity
Ergot (Methergine) Contraindications
- HTN
- Peripheral disease
- Raynauld’s
- Hypersensitivity
Hemabate Contraindications
- Hypersensitivity
- Asthma
- Active cardiac, pulmonary, renal, or hepatic disease
Misoprostol Contraindications
- Hypersensitivity
- Pregnancy; promoted for PPH where it is not possible to use other uterotonics
PPH Treatment if medications fail
- Bakri balloon
- B-lynch suture
- Uterine artery ligation
- Hypogastric artery ligation
- Uterine artery embolization
Last Resort Treatment for PPH
- Hysterectomy
Prolapsed Umbilical Cord
- Umbilical cord prolapses out thru the cervix into the vagina prior to delivery
- Cord gets compressed by presenting part, thus fetus does not get oxygen
Prolapsed Umbilical Cord Diagnosis
- Suspect prolapse when there is sudden prolonged deceleration or fetal bradycardia
- Confirm by vaginal exam—>palpate pulsating cord as presenting part or over presenting part
Prolapsed Umbilical Cord Treatment
- Lift presenting part off cord and keep it off cord…DO NOT REMOVE HAND!!!!!!!!
- Immediate transfer to OR for cesarean delivery
- Do not remove hand until surgeon instructs
Amniotic Fluid Embolism
- Amniotic fluid enters the maternal circulation
- Anaphylactic raction
- Seen in the late stages of labor or immediate postpartum
*can even be seen after DandE
Amniotic Fluid Embolism Clincal Presentation
- Very rapid progression
- May begin w/ gasps, seizures
- Abrupt onset of hypotension, hypoxia, DIC resulting in massive hemorrhage
- Sudden cardiac collapse/arrest
- Prognosis dismal—> likely to result in death
Amniotic Fluid Embolism Management
- CPR
*airway support
*oxygen
*circulatory support
- Blood products
Preeclamsia
- Development of hypertension w/ proteinuria >20wks
- Cause unknown
- Disorder of vasopressin
*vasoconstriction and intravascular depletion
*all organs show signs of poor perfusion
Preeclampsia Risks
- Primiparous
- Multigestation
- Prior history of preeclampsia
- Vascular disorders: chronic HTN, DM, Lupus
- 1st degree female relative w/ preeclampsia
- Young maternal age or AMA
Preeclampsia Presentation
- Headache
- Visual changes
- SOB
- RUQ/epigastric pain
- N/V
- Swelling of upper extremities/face
- Hypertension
- Proteinuria
- Lab abnormalities
Preeclampsia Labs
Normal hypertensive lab screening
- CBC
- Urine- 24hr urine, protein: creatinine ratio, or urine dipstick
- Creatinine
- Uric acid
- AST/ALT
- LDH
Preeclampsia Diagnosis Criteria
- BP >140/90
- Protein >300mg in 24hr urine or protein:creatinine ratio
- Lab abnormalities
*thrombocytopenia
*elevated liver enzymes
*elevated uric acid
*elevated creatinine
Preeclampsia Treatment
- Delivery
- If stable and preterm can monitor
- Magnesium sulfate as a prophylaxis for seizures
- If HTN is severe, give antihypertensive to prevent CVA
*medication does not treat preeclampsia
*can give labetalol, nifedipine, hydralazine
Eclampsia
- Seizures may be seen up to 12wks postpartum
Eclampsia Treatment
- ABC’s supportive
- MgSO4 to prevent further seizures
*consider other antiepileptics as necessary
- EFM
- Delivery
8when pt recovers from seizure
