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 and Gynecology, March, 2014 Abruption • Premature separation of the • Incidence: about 1% of • Leading cause of vaginal bleeding in the latter half of • 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 • Preeclampsia • Smoking • thrombophilias • Trauma • Advanced • Cocaine use maternal age • Multifetal • PPROM gestation • Intrauterine • Hypertension infection • hydramnios

Signs/Symptoms of abruption • Uterine pain-may be mild-severe • Back pain • Vaginal bleeding • Uterine irritability,UC’s,hard/tender abdomen • • 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 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 , 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 • Smoking • Cocaine • Male • Non-white race

Manifestations & Diagnosis • Clinical • Diagnosis Manifestations – Transabdominal/tr – Painless vaginal ansvaginal bleeding in 2nd ultrasound

half of pregnancy – Spec exam to R/O – Bleeding and other causes of contractions bleeding

Maternal & Fetal Effects • Maternal • Fetal – Hemorrhage – Prematurity – hypovolemic shock – IUGR – Rh sensitization – Congenital – Anemia abnormalities – Abnormal – Anemia implantation of placenta – 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 • Achieve and/or maintain maternal hemodynamic stability – Monitor VS & urine output – Estimate blood loss – Evaluate labs – IV fluids/transfusion Acute/Emergent Goals/Management •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 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 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

• 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 causes myocardial capillary damage & pulmonary capillary damage, left heart failure, and acute respiratory distress syndrome Phase II • Hemorrhagic phase characterized by massive hemorrhage with & DIC – Fatal consumptive 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 • 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 • Rupture – May be – Sharp, tearing pain asymptomatic – Bleeding – S/S may develop – UC’s may be absent over several hrs – Fetal bradycardia – Minimal bleeding – May be unable to – “Normal” UC’s reach presenting part – FHR may be – May see fetus reassuring 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 – 2° fundus inverts through cervix – 3° fundus inverts & protrudes beyond vulva Contributing Factors and S/S

• Traction to cord • Hemorrhage • Fundal pressure • • Fundal • May visualize the implantation uterus • Unable to palpate • Uterine atony uterus or can • Leimyomas palpate a • Adherent placenta depression in the uterine fundus • Fetal macrosomia • Use of oxytocin Management of Inversions

• Prevention best - • Blood replacement, don’t pull on cord! labs to assess coag • Immediate attempts • Notify Anes. & OR to replace uterus • Strict I&O • Tocolysis to relax • Monitor maternal ECG uterus • Antibiotics • Closely monitor VS • Possible NG • Withhold pitocin • Monitor bleeding, until uterus replaced correct fundal • O2 @ 15 LPM massage • IV fluid, large bore 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 or protruding from vagina Management of Cord Prolapse • Call for help • Cover cord with sterile • DC pitocin saline-soaked gauze • Relieve cord • O2 compression • Prepare for emergent against cervix C/S & neo resuscitation • Minimize cord • Consider tocolytics manipulation • Assess FHR • Knee-chest or • Bladder inflation trendelenberg – Prolapse Kit • Do not remove hand! 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 • Rx/Interventions – Inability to get – Immediate respiratory support air, dyspnea (PPV) – Loss of – Atropine & ephedrine consciousness for C.O – Bradycardia – IV fluids – Hypotension – Elevate legs – Respiratory – Maintain calm arrest – Deliver w/in 4-5’ if cardiac arrest Systemic Local Toxicity • S/S • Rx/Interventions – Ringing in ears, – Establish airway, O2 tingling around per PPV mouth, – Intubate restlessness, nervousness, – Valium for seizures blurred vision, – Lateral positioning incoherent speech – IV fluids, ephedrine • Muscle twitching – Atropine (brady) • Convulsions – 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) • Impaction of the fetal shoulders within the maternal bony – 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 • Prior large baby • Maternal • Prior dystocia • Excessive wt gain • Midforceps/vacuum • Abnormal labor • progress • Macrosomia • Disproportionate • Abnormal pelvis fetal growth • > maternal age • Multiparity • Short stature • Male infant • 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 • Maternal – Anoxia, – Extensive vaginal asphyxia & perineal – Erb’s palsy lacerations – Fx clavicle – Emotional trauma – Brain damage – Death Management of Dystocia • Labor Mechanisms – Engagement – Descent – Flexion – Internal rotation – Extension – External rotation – Expulsion

Management of Dystocia

• Early recognition: • May cut larger epis double chin, “Turtle Sign” • Notify peds/anes. • Note time head • Place patient in delivers lithotomy at edge • Note time dystocia of delivery recognized bed/table • Signal 1 min. intervals 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 - • 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 )

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