1112 6416 Obstetric Emergencies

8/4/2019 1112 6416 Obstetric Emergencies

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Introduction

to

obstetric emergencies


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Placenta previa

The abnormal implantation of theplacenta in the lower uterine segment

most common cause during the second

half of pregnancy

painless, bright red color without

warning

3 types based on degree internal

cervical os is covered by placenta

marginal; partial ;complete .


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Placenta previa (contd)

Maternal morbidity and mortality

Hemorrhage, infection, preterm labour

Fetal risks include malpresentation and

congenital anomalies ;

Diagnosis and medical management

Standard diagnosis is transabdominal

ultrasound examination

Accurate to 97%


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Placenta previa (contd)

Diagnosis and medical management

(contd)

N/C : woman may be hospitalized for closemonitoring

Bed rest

Elective cesarean section before onset ofdelivery


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Abruptio placenta

premature separation of the normallyimplanted placenta after the 20th week ofpregnancy or during labor

uterine tenderness, rigid, pain, N/V 3 types

partial separation with concealed bleeding;

complete separation with concealedbleeding;

partial separation with apparenthemorrhage.


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Abruptio placenta (contd)

Complications

anemia, fetal death,

disseminated intravascular coagulation Nursing Care

Early detection & monitoring

Prepare for Cesarean birth


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Maternal implication of abruptio

placentae

Damage to uterine wall

Trigger large amount of thromboplastin released into the maternalblood supply

Trigger the development of DIC and hypofibrinogenemia ; blood

no longer coagulate

Moderate to severe hemorrhage (hemorrhagic shock)

If not rapidly reversed, renal failure, shock and death


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Fetal-neonatal implication abruptio placentae

Perinatal mortality associated with abruptio placentae(25-35%) (Perry, 2000)

In completed separation , 100% mortality rate

In less severe case, the rate of survival depends on :

level of maturity and time of delivery. (best delivered

within 20 minutes)

Complication : preterm labor, anemia and hypoxia

Irreversible brain damage of the fetus

Prompt action of the health care team


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Prolapse cord

A prolapsed umbilical cord result when umbilicalcord precedes the fetal presenting part when rupture

of membrane occur and presenting part is not well

engaged in the pelvis.

Pressure is placed on the umbilical cord

Vessel carrying to and from the fetus are compressed

Fetal distress (The cord is further compressed with each

contraction if labour start )


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Premature rupture of membrane (PROM)

Def : spontaneous rupture of the membranebefore the onset of labor at any gestational

age.

Cause : unknown; women complains suddengush of fluid or a slow leak of fluid from the

vagina.

Cx: infection e.g chorioammionitis Fetal complications e.g congenital pneumonia,

sepsis and meningitis

Cord prolapse, oligohydramnios cord

compression


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PROM (contd)

Common diagnostic testing

Nitrazine text for the pH of vagina (from yellow to

blue; 7.1-7.3);

Ultrasound for women who are not in labour;

digital examination should not be performed to

determine fetal presentation in these women


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PROM Clinical Therapy

A laboring woman with confirm rupture

membrane should be kept bed rest until fetal

head is well engaged .

FHR should be monitored for at least 1 fullminutes after spontaneous rupture of

membrane or amniotomy performed

If fetal bradycardia detected, vaginal exam isperformed to rule out cord prolapse.


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PROM Clinical Therapy (contd)

If a loop of cord is discovered, the examiner s

gloved fingers must remain in the vagina to

provide firm pressure on the fetal head (to

relieve compression )

Provide oxygen to mother via face mask

Woman assume a kneechest position or bed

is adjusted to trendeleberg position

Fetal heart monitoring

Emergenc casearean birth may be required


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Preterm labor

Labor that occur between 20th and 37th

weeks of gestation

Most causes are unknown Treatment is to delay birth


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Preterm labor

Sign and Symptom frequent uterine contraction (every 10 mins)

menstrual -like cramps

feelings of pelvic pressure, constant orintermittent

low backache, constant or intermittent

change in vaginal discharge abdominal crampingdiarrhoea ruptured membranes


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Preterm labor

High risk group :

Single, young mother

Lower socio-economic statusHypertensive disorders of pregnancy

Gestational diabetes

Antepartum hemorrhage

Congenital malformation


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Tocolysis

Use pharmacological agents to stoppreterm birth

Tocolytics : -adrenergics (Ritodrine, ivi)magnesium sulfate (less S/E)

S/E: tachycardia, palpitations,

nervousness, n/v, headache ,

hypotension.


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Tocolysis

Watch out for s/s of pulmonary

oedema: shortness of breath, chest

tightness, dyspnea, rales and rhonchiNote: respiration


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Tocolysis

Research has demonstrated that a gain of24 hours to several days is the best

outcome that can be expected with the use

of tocolyticsBest reason to use tocolytic therapy is to

administer glucocorticoids in an effort to

accelerate fetal lung maturity and reduceseverity of respiratory complications in

infants born preterm


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Abnormal labour

Dystocia: abnormally slow or difficult delivery

Cephalopelvic disproportion (CPD):

Disproportion between the size of the fetal

head and maternal pelvis.

Failure to progress: lack of progressive

dilataion / descent of the fetal presenting

part;


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Shoulder dystocia

An obstetrical emergency that occurs when

the axis of the fetal shoulders does not deliver

after the fetal head has been delivered.

Most anxiety provoking emergencies

Cx: PPH to mother; fetal injuries

Best management is prevention (DM, obesity,

macrosomia; oxytocin administraton,

instrumental delivery )

Special maneuver may help .


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Amniotic fluid embolism

Def: Entrance of amniotic fluid containing

particules of debris (e.g hair, skin,vernix or

meconium) into the maternal circulation,

resulting in hypoxemia, circulatory collapseand disseminated intravascular coagulation

(Chin , 2001; Ricci,2009)

Rare but is fatal event with sudden onset

Unable to predict or prevent


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Amniotic fluid embolism (contd)

Early identification is critical to improve

maternal and fetal outcomes.

Diagnosis: autopsy

Clinical presentation:

mother complains of difficulty breathing

s/s of cardiorespiratory arrest

Bleeding if DIC

Often unconscious and unresponsive


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Amniotic fluid embolism (contd)

Management

Immediate CPR

Intubate and oxygenate with 100% oxygen if

respiratory arrest

Place pulmonary artery catheter (Swan-Ganz

catheter) to monitor hemodynamic status

Treat cardiogenic shock by IV infusion Treat coagulopathy and blood loss

Monitor fetal conditioin, cesarean section as

needed


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Trauma in pregnancy

Physical trauma occurs in about 1 out of 12

pregnancies

Type:

blunt e.g car accident ; fall, domestic violence

penetrating trauma e.g knife wounds, gunshot

The clinical presentation depends on the

severity and the type of trauma

Placenta abruption may result from severe trauma


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Trauma in pregnancy

The initial management of the fetus is the

support of the maternal airway, breathing and

circulation

Once mother is stabilized, assess FHR and uteine contraction

by CTG (fetocardiotocography)

Abdominal USS

Determine C/S


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Emergency care for obstetric woman

Psychological support to the family

Explaine the situation and inform the need

of EOT,

Encourage husband / significant others to

stay with the women.

Prepare the EOT (NPO ,x-match, foley catheter,

skin preparation, consent , fetal heart

monitoring).


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Emergency care for obstetric woman

The well-being of the fetus depends entirelyon the status of mother .

Vital sign monitoring, report if there is any

abnormality.

Hypoxia and hypovolaemai must be treatedquickly and vigorously.

Patients who are in the last trimester ofpregnancy should be nursed wedged on tothe left side.


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Emergency C/S

Types of care to be delivered?


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The expectant family with loss


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Grieving the Loss

Grief is an individuals total response to a loss,including physical symptoms, thought, and

feelings, functional limitations and spiritual

reaction. Manifestation by certain behaviors such as

weeping or visiting a gravesite, which help the

person experience , accept and adjust to the

loss. The period of adjustment to loss is

known bereavement.


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Grieving the Loss (contd)

Parental and infant attachment can begin

before pregnancy with many hopes and

dreams for the future

Gestational age of baby influences neither

severity of grief response nor bereavement

process

When a baby dies, all members of a familyare affected, but no two family members

grieve in the same way


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Assessment of each family membersperception and experience of loss is important

Therapeutic communication and counseling

techniques can help families identify theirfeelings, feel comfortable in expressing theirgrief, and understand their bereavementprocess

Nurses need to be aware of their own feelingsof grief and loss to provide a nonjudgmentalenvironment of care and support for bereavedfamilies


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5 phases:

1. Denial of death of the fetus2. Anger resulting from feeling of loss,

loneliness and guilt

3. Bargaining4. Depression

5. Acceptance


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Nursing Care- Prior to birth

Assess and identify the family membersability to adapt to the loss, social support &

care Prepare the family for the birth: encourage

the couple remain together as much as theywish

Explain details of the plan of care and allowthe option of labor preference

Encourage the partner to express their feelingand concerns


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Nursing Care- After birth The woman is transferred to a quiet room away

from nursery

Support the family in viewing the stillborn infant Encourage the parents to see ,touch and name

the baby.

Allow the infant to remain with the family as longas the family desires.


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Nursing Care - After birth (contd)

Offer remembrances of the baby for theparent to keep ( i.e. lock of hair, baby bracelet,

foot print, hand prints or even a photo helpparents accept the reality of babys death andpromoting grieving process


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Nursing Caredischarge Focus on physical needs and adaptation of the

mother.

Facilating the familys grief work Provide an opportunities for religious or

spiritual support if required.

Refer to counseling services or communitysupport group

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1112 6416 Obstetric Emergencies