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.

• Discuss the nursing management of a precipitous labor and delivery.

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?

Placenta Previa

• Poor site chosen by zygote at implantation

• Can be complete, partial, or marginal

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

Velamentous Insertion

• Associated with earlier placenta previa which moved higher

• Photo is Velamentous insertion….

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%

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

(Lijoi, 2003)

Diagnosis

• Antepartum– Difficult to diagnosis– Transvaginal sonography with color doppler

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.

Vasa Previa

• Obstetrical emergency• Catastrophic implications for the fetus• Fetal outcome based on quick diagnosis, an emergency

cesarean and infant resuscitation capability

Treatment

• Antepartum Diagnosis– Scheduled Cesarean Section

• Intrapartum – Emergency Cesarean Section– Prepare for full infant resuscitation

Abruptio Placentae

• Definition: premature separation of the placenta (part or all) from the uterus

• Usually after 20 weeks

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%)

Incidence

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

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

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

Lab Findings

• Decreased H&H• Decreased coag factors• Presence of fetal-to-maternal bleeding

(detected by Kleihauer-Betke test)

Diagnosis and Medical Management

• Patient history• Physical exam• Lab studies• Ultrasound• Treatment depends on severity of abruption• Exam of placenta at delivery confirms

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)

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

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

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)

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

Clinical Manifestations

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

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

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

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

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

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

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

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

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

Disseminated Intravascular Coagulation

DEFINITION

• DIC: small blood clots develop throughout the bloodstream

• Blocking all blood vessels • Using up all the clotting factors

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

DIC triggers in pregnancy

• Placental abruption• HELLP syndrome• Sepsis• Retained IUFD• Amniotic fluid embolus

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

Physiological Signs

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

Testing- LAB WORK

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

TREATMENT

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

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

Etiology

• Potential hazard of ROM• Contributing factors:

– Long cord – Malpresentation or unengaged presenting part– Breech presentation

Diagnosis

• Variable decelerations during uterine contractions

• Fetal bradycardia• Cord felt or seen protruding from vagina

Medical Management

• Examiner holds baby away from cord• Reposition patient• Do not handle cord• Cover exposed cord with wet saline-gauze• Prepare for rapid delivery

– Usually crash C/S

Fetal Outcomes

• With prompt recognition & rapid delivery fetal outcome is excellent

• Unrelieved cord compression >5min

risk of significant CNS damage and

fetal death

Precipitous Labor and Delivery

Kathleen Murray, CNM, MN Lori Valentine, RNC

Objectives

• Define precipitous labor and delivery

• Discuss the nursing management of a precipitous labor and delivery.

Definition

• Rapid labor for which the usual preparations and attendants are not present.

• The nurse assumes primary responsibility for the physical and psychological safe passage for mother and baby.

Signs and Symptoms

• May display extreme agitation and discomfort

• Or, may be comfortable• Increase in bloody show,

grunting , spontaneous pushing

Physiology• Low cervical resistance with

strong contractions• Relaxed pelvic muscles, low

resistance to fetal descent• Multiparous, with previous

vaginal births, in vigorous labor • Also can be caused by oxytocin use!!

Complications

• Uterine rupture• Pelvic tissue trauma• Fetal hypoxia• Fetal head trauma• Erb’s palsy

Uterine Rupture

• Tumultuous labor with abnormally strong uterine contractions and a firm closed cervix

Pelvic Tissue Trauma

• 3rd or 4th degree laceration involving the perineal body and anal sphincter

• Cervical laceration• Urethral laceration

Fetal Hypoxia

• Vigorous labor low fetal oxygenation due to poor placental perfusion

• Increased risk of meconium • Increased risk for an acidotic newborn

requiring resuscitation

Fetal Head Trauma

• Resistance of the birth canal to expulsion of the head, causing intracranial trauma

Erb’s Palsy

• Injury of the brachial plexus affecting the nerves that control the muscles of the arm and hand

Nursing Responsibility

• Delivering baby is outside the usual scope of practice for the intrapartum nurse

• Responsible for the adequate assessment of mother and fetus

• Appropriate communication with the MD or CNM about the patient’s status

• Documentation

Affirmative Duty Actions

• Actions the obstetric nurse is required to perform legally include making vital assessments, recognizing the significance of findings, and taking actions

• Failure to act may place the nurse in legal jeopardy (malpractice case: nurse managed a complicated birth & the baby died)

• Nurse held responsible for: failing to assess the situation adequately and neglecting to notify the MD promptly

• Remain calm – project confidence that the situation is under control

• Never leave the patient. Make calls from the room for assistance.

• Continuously reassure the patient and explain what is happening

• Encourage patient to pant when she can, and bear down gently only when she must.

Nursing Interventions

Management and Nursing Care

• Precipitous birth kit

• Need cord clamps, scissors, & bulb syringe

• Call for more nurses

• If time permits, scrub/glove/drape

Positioning

• Leave bed intact!

Relieves the nurse from worrying about catching a slippery baby

• Side-lying position can slow descent

Delivery in Vertex Presentation

• Gentle pressure with fingers against the fetal skull

• Don’t hold baby in!

Nuchal Cord

• Palpate for a cord. If loose, pull over head or slip over body as shoulders deliver

• If tight, clamp x 2 and cut between clamps• Or, Somersault manuever- deliver head, then

flex the head and torso into the mother’s groin. The rest of the body folds and somersaults out

Birth of body

• Assist shoulders by pressing down on the fetal head (for anterior shoulder) and then raising head (for posterior shoulder followed by body)

Vertex Delivery

• Suction mouth and nose prn

• Clamp & cut cord• Baby onto maternal abdomen. Provide

tactile stimulation/dry off with warm towels and cover

Breech Precipitous Delivery

• Buttocks usually presents first-maintain a hands off attitude until baby born to level of the umbilicus

• Then pull a substantial loop of cord to prevent tension on it during the delivery

Breech Delivery of Body• Cover lower half of baby with a towel to

provide warmth and good control during next maneuvers

• Birth of shoulders should be in transverse position

• With hands placed on bony parts of hips, gentle traction is applied downward until axillae are visible

• Lift baby’s body carefully upward to deliver each shoulder and arm

Breech Delivery of Head• Baby still should face downward• One hand under baby supporting body and

other hand over back with fingers over shoulders on either side of neck

• Gentle downward traction until nape of neck viewed, then lift carefully upward to allow face to clear perineum, head gently rolls out of the pelvis

• Flexion can be assisted by a 2nd person applying suprapubic pressure

Care of Newborn

• Provide tactile stimulation• Dry off baby with warm towels (if

heated-up warmer not available, stay skin to skin with mother!)

• Assess airway, breathing and circulation

• Assign APGAR scores

Maternal History in Precip Birth

• If uncertain pregnancy history, assess gestational age using the Ballard scoring system.

• Illicit drug use?

Delivery of Placenta

• Wait and observe• S/S of placental separation:lengthening of

cord, gush of blood, pt c/o cramping or pressure

• Gently pull down on cord as mother bears down

• Guard the uterus to prevent inversion of the uterus

Support placenta as it delivers to prevent tearing/retention of amniotic membranes

Firm massage controls bleeding Initiate breastfeeding

Control bleeding from lacerations by applying ice in sterile glove, or direct pressure with sterile gauze

Delivery of Placenta

ReferencesOB Emergencies and Precip Birth

• Creasy, R, et al, Maternal-Fetal Medicine Principles & Practice, 6th ed. 2009, Saunders Elsevier

• Cunningham, FG, et al., Williams Obstetrics 23rd ed. 2010, McGraw Hill

• Gilbert, E, Manual of High Risk Pregnancy & Delivery, 5th ed. 2010

• Perry, S. et al, Maternal Child Nursing Care, 4th ed., 2010, Mosby Elsevier

• International Vasa Previa Foundation, www.vasaprevia.org

• Lijoi, A, Brady, J, JAHFD, Nov 2003, Vol 16, Number 6, pp. 543-548

• Martin, EJ, Intrapartum Management Modules, 4th ed. 2010, Lippincott

• Mattson, S, Smith, JE, Core Curriculum for Maternal-Newborn Nursing 4th ed. 2011, AWHONN