1 OB meets the ED

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DOS CME Course 2014 1 DOS CME Course 2011 1 Oxtober 2010 1 Confidential

OB meets the ED

Ann Roach, MSN, RNC-OB, RNC-MNN, ACNS-BC

Clinical Nurse Specialist

Women’s and Children’s Services

Fairview Hospital

Cleveland Clinic

© Cleveland Clinic 2014

http://www.babyland.my/image/cache/data/uploads/2013/03/hand-knit-baby-socks-sky-blue-bear-3-650x650.jpg

My Bias

• Nursing • OB nursing

DOS CME Course 2014 2

Everybody has a Birth Story


2

Birth Story

Photo from personal files

1. Most common diagnoses for the OB patient presenting

to the Emergency Department

2. Discuss the steps of delivering a baby in the ER

Objectives


• 10 lunar months

• 280 days

• Trimesters

– 12-14 weeks

– 14-28 weeks

– 28-40 weeks

– Up to 12 weeks postpartum

• Photo retrieved 1/13/14 from http://scienceblogs.com/startswithabang/files/2012/11/larger.jpg

Magic Numbers in OB


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Go the Full

Forty

Who does this involve?

• Childbearing years

– 15-45

• Clinically

– 11-56

• Ideal

– 20-34

50% of all pregnancies are unplanned

• Optimal health prior to pregnancy

– Control your states and take your vitamins

– Stop smoking

• Antepartum issues are cared for at home

• Maternal mortality is on the rise

– Hemorrhage

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Physiologically

• Plasma volume increases 40-50% by week 30

• Hemodilution

– Red blood cells do not keep up

– Anemia

• Edema- not enough proteins in fluid

• Maternal cardiac output rises= increase in stroke volume,

increase in heart rate

– Heart displaced up and to the left

–PMI, CPR and murmurs

systemic vascular resistance falls

» BP decreases in 1st and 2nd trimesters

• Clotting factors increase—fibrinolytic activity decreases


Respiratory

• Thoracic breathers

• Flaring of rib cage

• Hyperventilation

• Improved Oxygen delivery

– LOWERS reserve----quicker to develop hypoxia

• Compensated respiratory alkalosis

Renal

• Distended ureters

– Prone to UTI’s

– Pyleonephritis

– PTL

GI

• Slowed

– Always considered to have a full stomach

– Gastric ph is lower

– Constipation

• Gallbladder

– Acute cholecystitis can lead to the second most common

nonobstetric surgical condition of pregnancy

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Diabetogenic State

• Prolonged circulating glucose

• Additional insulin

• Gestational diabetic

• Testing done at 28 weeks


Most General Practitioners Dislike OB


Photo retrieved 1/13/14 from http://2.bp.blogspot.com/-LIUzPJO-Wnc/UBpA2acQ9dI/AAAAAAAAAIs/iHroks2bxis/s1600/Pregnant+Woman.jpg

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• 25 yrs old

• Single

• FOB involved—when he wants to be

• Exhaustion

Meet Claire


Presenting to your ER

• C/O severe abdominal pain

• Pale

• BP 100/60, P105, R20

• Guarding of abdomen

Differentials=What are you thinking?

• Flu

• Appendicitis

• PID

• UTI

• Constipation

• Pregnancy

• Kidney stones

• Stress?

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LMP 7-8 weeks ago

• Missed period

• Positive pregnancy test

• Some bleeding?

Ectopics

• Implantation outside of uterus

• 97% are in the tube

• 2% of all pregnancies

• STD’s

• Previous surgeries

• Altered hormones

• Assisted reproduction

• Maternal smoking at time of conception

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• Torn blood vessels

• Maternal death

– Abdominal pain 100% of time

– Dull and achy lower quadrant-one sided

– Colicky

– Diffuse/constant/severe

• No fever---no infection

• Medical vs. Surgical


20 weeks

• Below 20- product of conception

• Abortion

– Spontaneous

– Induced

• Complete- pass all tissue

• Incomplete

• Inevitable

• After 20 weeks- Stillbirth--fetus

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Second Trimester Ultrasound


Photo retrieved 1/13/14 from http://medicalpicturesinfo.com/wp-content/uploads/2011/09/Omphalocele-5.jpg

http://1.bp.blogspot.com/-

MTnYg9aJjms/TcmCPzySjmI/AAAAAAAADq4/3hBWtf1q3ks/s1600/IMG_0569.jpg

Perinatal Loss

• Grief

• Your bias

• For your patients

• Treat every pregnancy like it matters

• Gather all tissue

• Burial is allowed for any GA

4 weeks


10

8 weeks


Perinatal Loss

• I am Sorry

• D&C

• D&E

• induction

• When?

• 20 weeks?

• Take your cues

from mom


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•http://2.bp.blogspot.com/-MJoqqHG4RwI/UWXM7pKGXeI/AAAAAAAAAXI/cmPtjXj91Yo/s1600/Fundal+Height.gif

Photo retrieved 1/13/14 from

Most important lesson

Meet Marge

• 35

• G3P2

• Vaginal bleeding

• squad

• 32 weeks


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Domestic Violence

Each encounter

• Safety questions

• Hidden abuse

• Child safety

– Child not related to adult members

• Abdomen seems to be the preferred site during

pregnancy

Recreational Drugs

• Use is increasing

• Baby is not born addicted—born dependent

• Withdrawal of newborn

• Nicotine withdrawal- day 3

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Abruptions

• Partial

• Complete

• Hidden

• 800 mL/min uterus

• Dislodge the placenta

Trauma

• Treat the mom

– She’ll treat the baby

• C-spine

– Tilt the board

• Seatbelt use

– Above the uterus, low on hips

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Back to Marge

• Home on bedrest

• Known placenta previa

• Vaginal bleeding

Take away

• Large bore IV’s


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Terry and her DKA

• Type I diabetes

• Non-compliant

• Multiple ER visits

• Didn’t believe

• Didn’t want

• Didn’t care


Placenta is not a filter

• Molecular size plays

a part

–Glucose crosses

–Insulin does not

• Baby’s get big

–Weight distribution

unequal

–Lung maturity delayed

• Glucose supply gone

with delivery

Implications for Delivery


Retrieved from http://blogs.babble.com/being-pregnant/files/2011/03/16-lb-big-baby.jpg

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• Task Force on Hypertension in Pregnancy

– Summary of findings, October 2013

• Chronic Hypertension

• Preeclampsia/eclampsia

• Chronic HTN with superimposed preeclampsia

• Gestational HTN

Preeclampsia


Eliminated the Dependence upon Protein

• In the absence of protein: Diagnosis is HTN in association with

• Thrombocytopenia

• Impaired liver function ( twice normal)

• New development of renal insufficiency

• Serum creatinine >1.1 mg/dL or doubled in absence of renal disease

• Pulmonary edema

• New onset cerebral or visual disorders

• Severe features S ≥ 160 D ≥ 110

Best Practice

• No LIGHTS

• No SIRENS

• No DRAMA

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Magnesium Sulfate

• 4-6 gms over 30 min

• Respiratory depression

• Loss of DTR’s

• Cardiac monitoring

What do you worry about?

• Eclampsia

• Seizures

• Stabilize the mom….then deliver the baby

• Can happen post delivery-up to 12 weeks

911

• Pregnant female, rapid labor

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Cardinal Movements

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•You are going to have to look

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Check the Neck

• Slip over the head

• Slip down the body

• Somersault the baby out

• Too tight?

• Clamp in 2 places and cut between clamps

• Nightmare

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Turtle Sign

Who is at risk

• Previous shoulder dystocia

• Large babies

• Diabetic mothers

• EVERYBODY

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Hands and knees

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Convection: transfer of heat to air

moving across and around body

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Radiation: transfer of heat between 2 objects

that are not in direct contact. Heat is

transferred from the warmer object to the

cooler one.

Conduction: transfer of heat

between 2 solid objects that are in

direct contact

Evaporation: heat loss by

conversion of liquid usually water

into vapor.

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Kangaroo Care

Breastfeeding


Photo retrieved from http://www.associatedobgyn.net/wp-content/uploads/2012/01/Breast-Feeding-Baby.jpg

Skin to Skin and What about Dads?


Personal photo bank

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Evaluating the Newborn

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Apgars

• Does not dictate resuscitation

– 1 min

– 5 min

• Well flexed extremities

• Spontaneous respirations

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•All about respiration – Stimulate to breathe

• IF……Suction mouth and nose

• O2-small ambu bag

• Chills baby

• 2 finger compression

• Heartrate less than 60

What if you see…….

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Life lesson #411

•What do you look for after you

deliver a baby?

What about that placenta?

• Separation within 30-60 mins of birth

– Perfect world- 10 to 15 minutes

• No pulling on cord

• Gush of blood with separation

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Bleeding post placenta

• Fundal/uterine massage

• Pitocin

• Breastfeeding

• Cytotec



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Fundal massage

Postpartum hemorrhage

• Uterine Atony

• Retained products of conception

• Infection

• Multiples

• Clotting disorder

Delivery

• 500 mL- vaginal delivery

• 1000 mL C/S delivery

• Amniotic fluid

• Subjective Blood loss

• Soaking of the pads

• Measure = Save

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Postpartum Hemorrhage


Retrieved from http://www.disease-picture.com/wp-content/uploads/2010/11/24/postpartum-hemorrhage-preventionbq.jpeg

Hemorrhage Cart

http://www.disease-picture.com/wp-content/uploads/2011/12/21/textbook-of-postpartum-hemorrhagero.jpg

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Intrauterine Balloon


http://a248.e.akamai.net/7/248/432/20101213122053/www.msdlatinamerica.com/ebooks/HysteroscopyVisualPerspectivesofUterineAnatomyPhysi ologyandPathology/files/2fcb81c822ce2793849f490b37e8cbf9.gif

Uterine Artery Embolization


Retrieved from http://www.natural-homeremedies.com/blog/wp-content/uploads/2012/06/Uterine-Artery-Embolization.jpg

Obstetric Drills

• Shoulder dystocias

• Hemorrhage

• Seizures

• Cord prolapse

• House wide


•http://www.scvmc.org/professionals/residency/obgyn/PublishingImages/OBDrillsPostpartumHem.jpg

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Questions??


Retrieved from http://vuoriclothing.com/community/wp-content/uploads/2011/03/heart-with-baby-feet.jpg

• Definition of Term Pregnancy. (Nov, 2013). Committee Opinion Number 579. ACOG, Society for Maternal-Fetal Medicine.

• Driggers, R., Seibert, D., (May, 2008). The Journal for Nurse Practitioners. 351-356.

• Guidelines for Perinatal Care 7th Edition. (2012). American Academy of Pediatrics & American College of Obstetricians and Gynecologists.

• Inherited Thrombophilias in Pregnancy. (Sept, 2013). Practice Bulletin Number 138. ACOG.

• Management of Preterm Labor. (June, 2012). Practice Bulletin Number 127. ACOG.

• Opioid Abuse, Dependence, and Addiction in Pregnancy. (May, 2012). Committee Opinion Number 524. ACOG, Committee on Health Care for Underserved Women and the American Society of Addiction Medicine.

• Simpson, K.R., Creehan, P. A., Perinatal Nursing, 4th Ed., AWHONN, Wolters Kluwer, 2013.

• Premature Rupture of Membranes. (Oct. 2013). Practice Bulletin Number 139. ACOG

• The Use of Chromosomal Microarray Analysis in Prenatal Diagnosis. (Dec. 2013). Committee Opinion. ACOG

References


DOS CME Course 2014 111 DOS CME Course 2011 111

1 OB meets the ED

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