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OBSTETRICAL EMERGENCIES

OBSTETRICAL EMERGENCIES. Kathleen Murray, CNM, MN, RN Larry Whorley, BSN. Objectives. Define and discuss nursing management for the following emergencies: vasa previa, abruption, rupture, amniotic fluid embolus, DIC, and prolapsed cord.

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OBSTETRICAL EMERGENCIES

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  1. OBSTETRICAL EMERGENCIES Kathleen Murray, CNM, MN, RN Larry Whorley, BSN

  2. Objectives • Define and discuss nursing management for the following emergencies: vasa previa, abruption, rupture, amniotic fluid embolus, DIC, and prolapsed cord. • Discuss the nursing management of a precipitous labor and delivery.

  3. True Obstetric Emergencies • Vasa Previa • Placental Abruption • Uterine Rupture • Amniotic Fluid Embolus • DIC • Prolapsed Cord • Precipitous Delivery What should the L&D nurse do in these critical situations?

  4. Placenta Previa • Poor site chosen by zygote at implantation • Can be complete, partial, or marginal

  5. Vasa Previa • Developmental disorder of the umbilical cord • Most dangerous type of velamentous insertion • Velamentous insertion= umbilical vessels run from umbilical cord, between the amnion and chorion, then into placenta

  6. Velamentous Insertion • Associated with earlier placenta previa which moved higher • Photo is Velamentous insertion….

  7. Incidence • Occurs 1 in 3000 births • More likely in low-lying placenta (smoker, prior C/S, preg. with multiples, assisted conception) • No danger to the mother • Fetal mortality 33-100%

  8. Etiology • Blastocyst implants into endometrium • Cord is central at first • Placenta erodes at bottom edge if in lower segment • New growth at top edge toward fundus • Vessels can’t migrate, are left behind

  9. (Lijoi, 2003)

  10. Diagnosis • Antepartum • Difficult to diagnosis • Transvaginal sonography with color doppler

  11. Signs and Symptoms • Intrapartum • Umbilical vessels might be felt on VE • FHR deceleration with VE • Heavy show with fetal tachycardia • Vaginal bleeding at ROM, sudden onset of fetal distress.

  12. Vasa Previa • Obstetrical emergency • Catastrophic implications for the fetus • Fetal outcome based on quick diagnosis, an emergency cesarean and infant resuscitation capability

  13. Treatment • Antepartum Diagnosis • Scheduled Cesarean Section • Intrapartum • Emergency Cesarean Section • Prepare for full infant resuscitation

  14. Abruptio Placentae • Definition: premature separation of the placenta (part or all) from the uterus • Usually after 20 weeks

  15. Classification of Detachment • Grade 0 – approx 250ml (<10% surface) • Grade 1- 250-500ml blood(10-20%) • Grade 2 – 500-1000cc (20-50%) • Grade 3 – >1000cc (>50%)

  16. Incidence • Occurs in 1/120 deliveries • 12% of stillbirths R/T abruption • 1 in 8 recurrence rate

  17. Etiology • Probably necrosis and ruptured spiral arterioles in endometrium, from: • HTN (chronic, gestational HTN, Pre-eclampsia) • Smoking • Blunt trauma to the abdomen • Grand-multiparity • ETOH, cocaine, caffeine • Prior abruption • Uterine abnormalities, fibroids • Preterm Premature ROM

  18. Clinical Manifestations • 80% have vaginal bleeding • Hard or rigid uterine tone • Uterine/abdominal/back pain 50% • Signs of silent bleeding – shock, oliguria • Non-reassuring FHR • Low-amp/high frequency contractions • Couvelaire uterus

  19. Lab Findings • Decreased H&H • Decreased coag factors • Presence of fetal-to-maternal bleeding (detected by Kleihauer-Betke test)

  20. Diagnosis and Medical Management • Patient history • Physical exam • Lab studies • Ultrasound • Treatment depends on severity of abruption • Exam of placenta at delivery confirms

  21. Interventions • Establish IV line(s) 18 gauge or larger • Obtain labs and Type and crossmatch 2-4 units packed red blood cells • Rapidly administer parenteral crystalloids or colloids • Avoid vaginal examinations • O2 per face mask at 10 L/min • Foley catheter • Prepare for emergent C-Section • Monitor Maternal V. S. / FHR, verify fetal life • Prepare for potential DIC (happens 20% of abruptions)

  22. Nursing Care Plan • Maternal stabilization • Maintain urine output of 30-60 mL/hour • Explain status and answer questions straightforwardly to allay anxiety • Position for comfort • Anticipate grieving

  23. Uterine Rupture • Actual separation of the uterine myometrium, with ROM and extrusion of the fetus into the peritoneal cavity. • Uterine dehiscence: a partial separation of the old scar; membranes intact

  24. Incidence & Etiology • Occurs 1-8 per 1000 births (.09% to .8%) • Uterine dehiscence occurs 2.0% of VBACs • Related to: • Previous uterine surgery scar • Hyperstimulation of the uterus • Trauma • Spontaneous (very rare)

  25. Risk Factors Associated with Uterine Rupture • Previous uterine surgery or curettage • High dosages of oxytocin • Prostaglandins (misoprostol, dinoprostone) • Tachysystole • Grand multiparity (greater than 4) • Abdominal trauma • Midforceps rotation • External cephalic versions

  26. Clinical Manifestations • Sudden fetal distress • Abdominal pain • Syncope, pallor, vomiting, shock • Maternal tachycardia • Vaginal bleeding • Presenting part ascent

  27. Medical Management • Maternal hemodynamic stabilization • Vital signs—observe for shock • Note blood loss amounts (weigh chux) • Maintain IV; order blood • Immediate Cesarean birth • Alert needed staff • Move quickly to OR • Uterine defect is repaired, or Hysterectomy

  28. Things to Remember • Risk of uterine rupture increases with the number of previous incisions. • For TOL for VBAC: • Surgeon in-house & available throughout labor • Anesthesia in-house & available throughout labor • Prostaglandin contraindicated in VBAC patient • Avoid or minimize use of oxytocin in labor for VBAC

  29. Stop here to play Kathleen’s game for nurses about Vaginal Bleeding s/s

  30. Amniotic Fluid Embolus (AFE) • AFE results from amniotic fluid entering maternal venous circulation. • Also called:anaphylactoid syndrome of pregnancy • 3 pre-requisites: • Ruptured membranes • Ruptured uterine or cervical veins • A pressure gradient from uterus to vein • Can occur before, during or after delivery

  31. Incidence & Etiology • Occurs 1/8000 to 1/80,000 • AFE associated with 85% maternal / fetal mortality. Most surviving mothers have brain damage, and 100% develop DIC • Common factors: Perhaps: male infant, hx allergies • Former list of risk factors was: • Strong uterine contractions • Meconium in amniotic fluid • Premature placental separation • LGA, hard birth, stillborn • Older mom, multipara

  32. Clinical Manifestations • Acute onset of respiratory distress • Dyspnea, cyanosis • Chest pain • Loss of consciousness, seizures • Pulmonary edema • Acute onset of circulatory collapse • Severe hypoxia • Severe hypotension • Acute onset of DIC • Fear of death

  33. Diagnosis & Medical Management • Detection of fetal squamous cells, hair, lanugo, mucin, vernix, &/or meconium in maternal blood and lung fields is the cornerstone of diagnosis • Initial Treatment: • Cardiopulmonary resuscitation w/oxygen • Circulatory support with blood components

  34. Nursing Care Plan • Ensure IV access • Initiate CPR • Give oxygen at 10 L/min • Assist with intubation • Observe for s/s of shock, coagulopathy • Help patient deal with fear of dying • Provide explanation of emergency for family members

  35. DisseminatedIntravascularCoagulation

  36. DEFINITION • DIC: small blood clots develop throughout the bloodstream • Blocking all blood vessels • Using up all the clotting factors

  37. DIC: a Cascade • Starts with stimulation of coagulant • Consumption of clotting factors • Failure of clotting at the bleeding site • Microthrombi formation throughout the circulatory system • Clotting factors get all used up • Fibrinolysis and Fibrin Degradation Products reduces the efficacy of normal clotting

  38. DIC triggers in pregnancy • Placental abruption • HELLP syndrome • Sepsis • Retained IUFD • Amniotic fluid embolus

  39. Signs and Symptoms • DIC usually develops rapidly • Uncontrolled bleeding- cuts, IV site, mouth, nose, vagina, skin, into urine • Hidden intestinal, placental, abdominal, brain bleeding • Shock develops

  40. Physiological Signs • Easily bruises • IV Site bleeding • Abnormal vaginal bleeding • ROM- large blood loss • Tachycardia • Hypotension • Decreased urinary output • FHR- Tachy then Bradycardia

  41. Testing- LAB WORK • FDP- HIGH levels • PT-HIGH • PTT- HIGH • Bleeding times- INCREASED • Serum Fibrinogen- LOW • Platelets- LOW • H.E.L.L.P. Syndrome

  42. TREATMENT • IMMEDIATE DELIVERY- CRASH C/S • 16 gauge IV • Oxygen • Right hip roll until delivered, etc. • Transfusion blood products • Transport to ICU

  43. Prolapsed Cord • Definition: umbilical cord lies beside or below the presenting part of the fetus. • Occurs in 0.3% to 0.6% of all pregnancies

  44. Etiology • Potential hazard of ROM • Contributing factors: • Long cord • Malpresentation or unengaged presenting part • Breech presentation

  45. Diagnosis • Variable decelerations during uterine contractions • Fetal bradycardia • Cord felt or seen protruding from vagina

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