Obstetrical

Emergencies

Avera McKennan Hospital &

University Health Center

•“there's no harm in hoping for the best as long as you're prepared for the worst.” ― Stephen King, Different Seasons

OB Emergencies…

• Do not happen often, but when they do…. Seconds do matter

• Important for everyone to act together as quickly as possible

• Anticipate possible problems, think 1-2 hours ahead

• Be assertive – make sure others know the importance of the emergency

• Patient care emergencies may occur at any time in any setting, particularly the inpatient setting..

• It is important that obstetrician–

gynecologists prepare themselves by

assessing potential emergencies,

establishing early warning systems,

designating specialized first

responders, conducting emergency

drills, and debriefing staff after actual

events to identify strengths and

opportunities for improvement.

Having such systems in place may

reduce or prevent the severity of

medical emergencies

Excellent communication and

teamwork will further increase

the efficiency and effectiveness

of the emergency response.

ACOG Committee Opinion, Preparing

for Clinical Emergencies in Obstetrics and

Gynecology, March, 2014

Abruption • Premature separation of the placenta

• Incidence: about 1% of pregnancies

• Leading cause of vaginal bleeding in the latter half of pregnancy

• Maternal effect depends primarily on severity

• Fetal effects depend on severity and gestational age

• Often associated with fetal death when involving more than 50% of the placenta

Risk Factors for Abruption

• Prior abruption

• Smoking

• Trauma

• Cocaine use

• Multifetal

gestation

• Hypertension

• Preeclampsia

• thrombophilias

• Advanced

maternal age

• PPROM

• Intrauterine

infection

• hydramnios

Signs/Symptoms of abruption

• Uterine pain-may be mild-severe

• Back pain

• Vaginal bleeding

• Uterine irritability,UC’s,hard/tender

abdomen

• Fetal distress

• Signs of hypovolemia and/or shock,

may be without visible blood loss

• May be asymptomatic

Tachysystole

Diagnosis

• Physical exam, assessing

patient’s S/S

• Ultrasound to R/O placenta

previa/identify retroplacental

hematoma

• Lab values

• Examination of placenta at

delivery

Placental Abruption

Maternal Effects

• Excessive blood loss

• DIC

• Hypovolemic shock

• Renal failure

• Adult Respiratory Distress Syndrome

• Multiorgan failure

• PP hysterectomy

• Death (rarely)

Fetal Effects

•Hypoxemia

•Asphyxia

•Low birth weight/IUGR (chronic

abruption)

•Preterm delivery

•Death

Management of acute

abruption •Prompt evaluation

•Continuous fetal monitoring

•Establish IV access/draw labs

•Notify blood bank so replacement products are

readily available

•Monitor VS closely

•Keep maternal oxygen saturation >95%

•Notify anesthesia of potential emergency

cesarean

•Delivery

Placenta Previa

• Presence of placental tissue

that extends over or lies

proximate to the internal

cervical os

• Incidence: 3.5-4.6 per 1000

births

• Pathogenesis is unknown

Descriptions

• Low-lying –The placenta is in the

lower portion of uterus, but not truly a

previa

• Marginal – The placental is adjacent

to or at the margin of the internal os

• Partial – The placental edge appears

to cover part, but not all, of the internal

os

• Total – The placenta completely

covers the internal os

Risk Factors for Previa • Previous placenta previa

• Previous c-section/uterine surgery

• Multiple gestation

• Multiparity

• Infertility treatment

• Previous abortion

• Smoking

• Cocaine

• Male fetus

• Non-white race

Manifestations & Diagnosis

• Clinical

Manifestations

–Painless vaginal

bleeding in 2nd

half of pregnancy

–Bleeding and

contractions

• Diagnosis

–Transabdominal/tr

ansvaginal

ultrasound

–Spec exam to R/O

other causes of

bleeding

Maternal & Fetal Effects • Maternal

– Hemorrhage

– hypovolemic shock

– Rh sensitization

– Anemia

– Abnormal

implantation of

placenta

• Fetal

– Prematurity

– IUGR

– Congenital

abnormalities

– Anemia

– Malpresentation

Asymptomatic

Goals/Management • Determine whether the previa resolves

with increasing gestational age – Serial ultrasounds

• Reduce the risk of bleeding – Avoid intercourse and exercise after 20 weeks

– Decrease overall physical activity in 3rd trimester

• Reduce the risk of preterm birth

• Achieve and/or maintain maternal

hemodynamic stability

–Monitor VS & urine output

–Estimate blood loss

–Evaluate labs

– IV fluids/transfusion

•Determine if emergent cesarean delivery is

indicated -Consider tocolysis to decrease contractions

which may promote placental separation and

bleeding

-Indications for delivery include: A

nonreassuring fetal heart rate tracing, life-

threatening refractory maternal hemorrhage,

or significant bleeding after 34 weeks gestation

Acute/Emergent

Goals/Management

Abnormal Implantation

• Accreta - placenta attaches directly

to myometrium

• Increta - invades the myometrium

• Percreta - penetrates through the

myometrium

Risk Factors • Previous cesarean delivery

• Placenta previa

• Advanced maternal age

• multiparity

• Endometrial defects (Asherman syndrome)

• Submucous leimomyomata

• Myometrial damage (myomectomy)

• Thermal ablation

• Uterine artery embolization

Diagnosis

•The diagnosis is usually

established by ultrasonography

and occasionally supplemented

by magnetic resonance imaging

(MRI).

Management

• Delivery planning

–cesarean with hysterectomy

–Uterine conservation may be

attempted if fundal or posterior

placenta accreta

• Maintain hemodynamic status,

prevent shock

–2 large bore IVs

–Cross-matched blood available

Velamentous cord insertion/

Vasa Previa

• Velamentous insertion -

umbilical vessels diverge as they

traverse between the amnion and

chorion before reaching the

placenta

• Vasa previa- fetal blood vessels

are present in the membranes

covering the internal os

Velamentous cord insertion/

Vasa Previa

Velementous Insertion-

pathogenesis • Pathogenesis is unknown

• Most popular hypothesis is that the cord

is initially inserted centrally, but its

location progressively becomes

peripheral as one half of the placenta

actively proliferates toward the well-

vascularized uterine fundus while the

other pole involutes

Amniotic Fluid Embolism

• Rare and frequently fatal obstetrical emergency

• Occurs in 1 in 30,000 births

• Maternal mortality 60-80%

• Diagnosis:

– Presence of fetal squamous cells, lanugo, vernix, mucin and/or meconium in the maternal pulmonary vascular space

Clinical Presentation

• 5 signs that occur in this sequence:

– Respiratory distress

– Cyanosis

– Cardiovascular collapse

– Hemorrhage

– Coma

Phase 1

• Pulmonary artery vasospasm with

pulmonary hypertension and

elevated right ventricular pressure,

causes hypoxia

• Hypoxia causes myocardial capillary

damage & pulmonary capillary

damage, left heart failure, and acute

respiratory distress syndrome

Phase II

• Hemorrhagic phase characterized

by massive hemorrhage with

uterine atony & DIC

–Fatal consumptive coagulopathy

may be the initial presentation.

Treatment

• Maintain airway via ET

tube/ventilations

• Restore cardiovascular equilibrium

• Central line – pulmonary artery

catheter

• Treat shock

Uterine Rupture

• Separation of the myometrium or

previous scar, with expulsion of

membranes and fetus into

peritoneal cavity

• Types: rupture & dehiscence

• Incidence: 1:1200 deliveries

Causes Uterine Rupture • Previous uterine surgery

• Hyperstimulation/hypertonus

• Grand multiparity

• Invasive or blunt trauma

• Obstructed labor

• Maneuvers within the uterus

• Midforceps rotation of the fetus

• Abnormal fetal lie

• Previous termination(s)

Signs/Symptoms

• Dehiscense

– May be

asymptomatic

– S/S may develop

over several hrs

– Minimal bleeding

– “Normal” UC’s

– FHR may be

reassuring

• Rupture

– Sharp, tearing pain

– Bleeding

– UC’s may be absent

– Fetal bradycardia

– May be unable to

reach presenting part

– May see fetus

through abd. wall

– Shock, CV collapse

Management Uterine Rupture

• Anticipate “at risk” pts and be ready

• Evaluate c/o unusual pain

• Physiologic 2nd stage management

• Assess uterine activity/tone

• Assess fetal status

• Stat C/S

• Maternal VS, pulse ox

• Maternal hemodynamic stabilization

• Accurate I&O

Uterine Inversion

• The turning “inside out” of the uterus

• 1:2,500 - 3,600 births

• Types of inversion

–1° fundus inverts, but not

through cervix

–2° fundus inverts through cervix

–3° fundus inverts & protrudes

beyond vulva

Contributing Factors and S/S

• Traction to cord

• Fundal pressure

• Fundal

implantation

• Uterine atony

• Leimyomas

• Adherent placenta

• Fetal macrosomia

• Use of oxytocin

• Hemorrhage

• Hypotension

• May visualize the uterus

• Unable to palpate uterus or can palpate a depression in the uterine fundus

Management of Inversions

• Prevention best -

don’t pull on cord!

• Immediate attempts

to replace uterus

• Tocolysis to relax

uterus

• Closely monitor VS

• Withhold pitocin

until uterus replaced

• O2 @ 15 LPM

• IV fluid, large bore

• Blood replacement,

labs to assess coag

• Notify Anes. & OR

• Strict I&O

• Monitor maternal ECG

• Antibiotics

• Possible NG

• Monitor bleeding,

correct fundal

massage

Fundal Massage

Prolapsed Cord

• Occult vs. overt

• Risk factors:

– ROM without engaged presenting part

– Malpresentation

– Preterm or IUGR fetus

– Multiple gestation

– Hydramnios

– Maneuvers

Clinical Manifestations

• FHR changes

• Cord palpated on vaginal

exam

• Cord visualized in vagina

or protruding from vagina

Management of Cord Prolapse

• Call for help

• DC pitocin

• Relieve cord

compression

against cervix

• Minimize cord

manipulation

• Knee-chest or

trendelenberg

• Do not remove hand!

• Cover cord with sterile

saline-soaked gauze

• O2

• Prepare for emergent

C/S & neo resuscitation

• Consider tocolytics

• Assess FHR

• Bladder inflation

– Prolapse Kit

Prolapse Kit

• Sterile no. 16 foley catheter, drainage tubing & bag

• Hemostat

• 1000 ml bottle sterile water, sterile bladder irrigation fluid, or 1000 ml NS with IV tubing

• Large syringe with pointed tip, preferably 60 ml

Bladder Inflation

• Insert foley cath & inflate balloon

• Clamp catheter with hemostat; remove drainage tubing

• Assemble IV of dextrose-free sol’n (i.e., NS), flush tubing

• Insert IV tubing into end of foley cath, remove hemostat.

• Infuse 400-750 ml into end of catheter & reclamp foley w/hemostat.

• Reattach foley drainage tube/bag – keep hemostat in place.

• Remove hemostat just prior to peritoneum incision

Labor Epidurals

• Regional block

– Local anesthetics

– Epinephrine

– Lipid-soluble opioid

• Test dose, bolus or

continuous, PCEA

option

Benefits to Epidurals

• Good to excellent analgesia

• Infrequent nausea

• Minimal sedation

• ↓ anxiety

• Retention of cough reflex

• ↓pulmonary dysfunction

• Can be used continuously for several hours

• Doesn’t cause significant slowing of labor

• Presence of catheter allows flexibility in type & amount of medication given

• Can be used for anesthesia if C/S necessary

Risks of Epidural

• Systemic toxicity

• High spinal/epidural

• Hypotension

• Inadequate or failed block

• Pruritis

• Nausea/Vomiting

• Respiratory Depression

• Intrapartum Fever

Risks of Epidural

• Severe Headache

• Epidural Hematoma

• Fetal bradycardia

BP & FHR Assessment

• Although insufficient evidence to

support definitive recommendations

about BP & FHR assessment, literature

review reveals that hypotension can

occur within the first 5 to 15 minutes

following initiation or re-bolus.

– Suggested: BP & FHR q. 5 minutes during

the 1st 15 minutes of initiation or re-bolus

Effects on Labor & Delivery

• A meta-analysis of randomized trials of epidural versus no epidural or no analgesia in labor found that epidural analgesia was associated with a longer second stage

• No significant effect on the duration of the first stage of labor

Effects on Labor & Delivery

• A meta-analysis of 38 randomized trials comparing all modalities of epidural with any form of pain relief not involving regional blockade or no pain relief in labor, concluded epidural analgesia did not significantly increase the risk of cesarean delivery

Effects on Labor & delivery

• The same meta-analysis found that neuraxial labor analgesia was associated with an increased risk of instrumental vaginal birth

Effects on Labor & Delivery

• An American College of

Obstetricians and Gynecologists

Committee Opinion concluded

that "maternal request is

sufficient medical indication for

pain relief during labor" and that

neuraxial anesthesia does not

increase the frequency of

cesarean delivery

Inadvertent Spinal

• S/S

– Inability to get

air, dyspnea

– Loss of

consciousness

– Bradycardia

– Hypotension

– Respiratory

arrest

• Rx/Interventions

– Immediate

respiratory support

(PPV)

– Atropine & ephedrine

for C.O

– IV fluids

– Elevate legs

– Maintain calm

– Deliver w/in 4-5’ if

cardiac arrest

Systemic Local Toxicity

• S/S

– Ringing in ears,

tingling around

mouth,

restlessness,

nervousness,

blurred vision,

incoherent speech

• Muscle twitching

• Convulsions

• Rx/Interventions

– Establish airway, O2

per PPV

– Intubate

– Valium for seizures

– Lateral positioning

– IV fluids, ephedrine

– Atropine (brady)

– Bretylium

Post-Epidural

• Catheter removal by RN if approved

per policy (documented competency)

– Withdraw slowly, do not force

– Assess for integrity of cath tip

– Band-Aid to site, monitor q. shift for

bruising, leaking fluid

• Carefully document amount wasted

(if narcotic added)

Shoulder Dystocia

• Impaction of the fetal shoulders within the maternal bony pelvis – Shoulders don’t deliver with maternal

expulsive efforts & gentle traction

• Incidence: 0.25% to 2.0% of all vaginal births

• Risk is greater in macrosomic infants – 11 x relative risk in > 4,000 gms

– 22 x relative risk in > 4,500 gms

Dystocia Risk Factors

• Maternal diabetes

• Maternal obesity

• Excessive wt gain

• Abnormal labor

progress

• Disproportionate

fetal growth

• Multiparity

• Male infant

• Prior large baby

• Prior dystocia

• Midforceps/vacuum

• Labor induction

• Macrosomia

• Abnormal pelvis

• > maternal age

• Short stature

• Post term

ADOPE

• A = Age

• D = Diabetes

• O = Obesity

• P = Prior large infant and/or

post dates

• E = Excessive weight gain

Dystocia Complications

• Fetal/newborn

– Anoxia,

asphyxia

– Erb’s palsy

– Fx clavicle

– Brain damage

– Death

• Maternal

– Extensive vaginal

& perineal

lacerations

– Emotional trauma

Brachial

Plexus Injury

Management of Dystocia

• Labor Mechanisms

–Engagement

–Descent

–Flexion

– Internal rotation

–Extension

–External rotation

–Expulsion

Management of Dystocia

• Early recognition: double chin, “Turtle Sign”

• Note time head delivers

• Note time dystocia recognized

• Signal 1 min. intervals

• May cut larger epis

• Notify peds/anes.

• Place patient in

lithotomy at edge

of delivery

bed/table

Turtle Sign

McRobert’s Maneuver

• Sharp hyperflexion of legs against abdomen

• Straightens the sacrum, angle of inclination

• Two assistants

Manual Pressure

• Gentle pressure on fetal head inferiorly & posteriorly

• Pushes shoulder into hollow of sacrum

• room for anterior shoulder

Suprapubic Pressure

• Direct pressure posteriorly & laterally above symphysis to dislodge anterior shoulder

• Empty bladder to avoid trauma & allow more room

Rubin Maneuver

Wood’s Screw Maneuver

Posterior Arm Delivery

Fracture of the Clavicle

• Diminishes the rigidity and size of

shoulder girdle

• Anterior clavicle broken first to

collapse the anterior shoulder and

dislodge it from behind the

symphysis

• Exert pressure away from lung to

avoid puncture

Gaskin Maneuver

• Hands & knee

(not knee chest)

• Mechanism of

action unknown

• Consider trying

first if no

epidural

Zavanelli Maneuver

(Cephalic Replacement)

• Manually return head to OA

• Flex the head & replace in vagina

• Hold fetal head in place until

C/birth

HELPERR

• H - call for help

• E - Episiotomy

• L - Legs back (McRobert’s)

• P - Suprapubic pressure (not fundal)

• E - Enter vagina for shoulder rotation

• R - Reach for posterior arm & deliver posterior shoulder

• R – Roll the patient (Gaskin) – Replace head

– Rotate head to A-P, flex, replace in vagina

– Proceed with emergent C/S

PERSPIRE

• P = Prepare (be prepared, every delivery)

• E = Episiotomy (cut generous epis)

• R = (Mc)Roberts (flex thighs to diameter)

• S = Suprapubic pressure (at MD’s request)

• P = Position (Gaskin maneuver, all 4’s)

• I = Internal (rotation, Wood screw maneuver)

• R = Rotation (presenting part clockwise)

• E = Emergency (fracture of clavicle and/or

Zavanelli maneuver)

Additional Nsg Responsibilities

• Note time head delivers on all deliveries,

call out 1 minute intervals

• Obtain additional help

• Detailed documentation of steps taken

and time for each

• Prepare warmer for resuscitation

• Observe for & be ready for complications

• Assess for fetal fx’s and injury

–Document full movement of arms, etc.

ACOG Committee Opinion, April, 2011

Oyelese Y, Ananth CV, Placental abruption, Obstet Gynecol, 2006

Oct;108(4)

Ananth CV, Kinzler WL, Placental abruption: Clinical Features

and diagnosis, UpToDate, 2014

Oyelese Y, Ananth CV, Placental abruption: Management,

UpToDate 2014

Lockwood CJ, Russo-Stieglitz K, Clinical features, diagnosis, and

course of placenta previa, UpToDate, 2014

Lockwood CJ, Russo-Stieglitz K, Management of placenta previa,

UpToDate, 2014

ACOG Committee Opinion, July, 2012

Resnik R, Management of placenta accreta, increta, and percreta,

UpToDate 2014

Grant, G. Adverse Effects of Neuraxial Analgesia and Anesthesia

for Obstetrics, UpToDate 2014