Obstetrical Emergency

1. Obstetrical Emergency Natalie Collins, BSN

2. Objectives Quick review of normal changes Maternal Abnormalities Risks to the baby Hemorrhage Treatment Resuscitation Guidelines

3. Acknowledgements • Thank you to MOANA for their continuous support of the students • Thank you to Webster University, the administration, my professors and classmates. For Hire: Webster University Class of 2013

4. Normal Anatomical and Physiological Changes • Hematologic • Dilutional Anemia • Increased Blood Volume • Hypercoaguable state • Decline in serum cholinesterase activity • Cardiovascular • Increased Cardiac Output • Supine Hypotension Syndrome • EKG Changes

5. Respiratory Changes • Hormonal Changes • Lung volume changes • Difficult Intubations • Response to volatiles

6. Uteroplacental Circulation • At term: uterine blood flow increased • UAP-UVP/UVR • Factors Decreasing blood flow: • 1) hypotension • 2) Vasoconstriction • 3) Uterine contractions

7. Pharmacology • Altered drug responses • Placental Transfer of drugs • Ephedrine and Neosynephrine • Local Anesthetics

8. Prevalence of Cesarean Births • Caesarean section rates on the rise • Multiple reasons for the drastic increase

9. Major indications for Cesarean section • Labor unsafe for mother and fetus • Increased risk of uterine rupture • Previous classic cesarean section • Previous extensive myomectomy or uterine reconstruction -Increased risk of maternal hemorrhage • Complete or marginal placental previa • Placenta abruption • Previous vaginal reconstruction

10. Maternal Risks • Dystocia • Increased heart rate or blood pressure • HELLP • Hemorrhage due to placental and uterine abnormalities • Infection • Multip • Repeat C-section

11. Fetal complications • Decelerations • Macrosomia • Fetal scalp pH <7.20 • Amniotic fluid problems

12. Immediate or emergent delivery • Fetal distress • Umbilical cord prolapse • Maternal hemorrhage • Amnionitis • Genital herpes with ruptured membranes • Impending maternal death

13. Fetal Monitoring • Baseline fetal heart rate 120-160 • Decreased vs Increased fetal heart rate • Variability

14. Decelerations

15. When is the decision made for an emergency C-section? • Collaborative effort • Differences in opinion of appropriate Decision to Delivery Interval (DDI) • Increased risk of hemorrhage

16. The Royal College of Obstetricians and Gynecologists. Classification of Urgency of Casearean RiskGood Practice (11).

17. What has to be done between decision todeliver and delivery Informed consent: • Consent form signed Intravenous access • Blood samples to be taken • Blood forms to be filled in • Bloods to laboratory • Intravenous fluids running • Premedication to be got from drug cupboard • Premedication drawn up • Premedication injected Anaesthetist informed • Operating department assistant informed • Consultant to be informed • Anaesthetist to arrive • Operating department assistant to arrive • Intravenous lines to be secured • Fetal scalp clip to be removed Theatre to be set: • Scrub nurse to scrub • Packs to be opened • Sutures to be opened Woman to be moved to theatre: • Woman to be moved on to theatre table Spinal: • Spinal drugs to be drawn up Monitoring to be attached • Spinal anaesthesia • Wait for block to work: Paediatrician to be present Catheter Shave Surgeons to scrub • Skin preparation • Skin incision Peritoneum opened Uterine incision

18. Indications for General Anesthesia • Fetal distress without epidural in place • Acute maternal hypovolemia • Coagulopathy • Inadequate regional anesthesia • Maternal refusal of regional anesthesia

19. General Anesthesia • 15% of all C-sections • Aspiration risk • Attach monitors, place parturient in left uterine displacement, preoxygenate, wait until surgeon is ready to cut. • Difficult airway preparation • RSI

21. General Anesthesia • Agents Propofol 2.5mg/kg Succinylcholine 1-1.5mg/kg • Inhalational Maintenance • After delivery medications • Extubate Awake!

22. Frequency of Postpartum Hemorrhage in Maternal Mortality • 10.5% of all live births are associated with obstetrical hemorrhage. • Primary and Secondary hemorrhage • 7 year study • AMTSL

23. Placental and Uterine Abnormalities • Antepartum Hemorrhage -Placenta Previa -Placenta Abruption -Uterine Rupture

24. Post Partum Hemorrhage -Accreta, Increta, Percreta -Uterine Atony -Acute Uterine Inversion

25. Classification of Hemorrhage

27. Uterotonic Medications • Pitocin • Ergot Alkaloids • Prostaglandins Uterine Massage

28. Prostaglandin F2 Alpha • Prostaglandin F2 alpha can be given locally or intramyometrially with a recommended dose of 250mcg. • Side effects are similar • 2000 Cochrane Review

30. Invasive Treatments • Retained placenta removal • Balloon tamponade • Arterial embolization • Uterine compression sutures

31. Fluid resuscitation • Susceptibility of massive blood loss • When to transfuse • What about crystalloids? • Hemorrhagic changes in coagulopathy • Cations • Cell Salvage

32. Blood Components

33. Conclusions • Identify risks for hemorrhage • Be prepared for general anesthesia in all situations • Intervene early to reduce complications • Effective communications with team members and obstetrician during all emergencies.

34. Thank you! QUESTIONS??

35. References • Borgman MA, Sinella PC, Perkins JG, et al. The ratio of blood products transfused affects mortality in patients receiving massive transfusions at a combat support hospital. • Smith JR, Brennan BG. Post partum hemorrhage 2007. Accessed April 9, 2012 from www.emedicine.com/med/topic3568.htm • World Health Organization. Attending to 136 million births, every year: make every mother and child count: the world report 2005, Geneva: WHO; 2005. • Ahonen J, Stefanovic V, Lassila R. Management of post-partum haemorrhage. ActaAnaesthesiol Scand. 2010;54(10):1164-1178. • Akhtar Z, Qazi Q, Khan I. Prostaglandin F2 alpha: An effective alternate to surgical control of postpartum hemorrhage in uterine atony. JPMI: Journal of Postgraduate Medical Institute. 2010;24(1):27-30. • CaberoRoura L, Keith LG. Post-partum haemorrhage: Diagnosis, prevention and management. Journal of Maternal-Fetal & Neonatal Medicine. 2009;22:38-45. • American College of Obstetricians Gynecologists Optimal goals for anesthesia care in obstetrics. ACOG Committee opinion #256.Washington DC: ACOG; 2001

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