Obstetrical emergency
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Obstetrical Emergency. Natalie Collins, BSN. Objectives. Quick review of normal changes Maternal Abnormalities Risks to the baby Hemorrhage Treatment Resuscitation Guidelines . Acknowledgements . Thank you to MOANA for their continuous support of the students

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Obstetrical emergency

Obstetrical Emergency

Natalie Collins, BSN


Objectives

Objectives

Quick review of normal changes

Maternal Abnormalities

Risks to the baby

Hemorrhage

Treatment

Resuscitation Guidelines


Acknowledgements

Acknowledgements

  • Thank you to MOANA for their continuous support of the students

  • Thank you to Webster University, the administration, my professors and classmates.

For Hire: Webster University Class of 2013


Normal anatomical and physiological changes

Normal Anatomical and Physiological Changes

  • Hematologic

    • Dilutional Anemia

    • Increased Blood Volume

    • Hypercoaguable state

    • Decline in serum cholinesterase activity

  • Cardiovascular

    • Increased Cardiac Output

    • Supine Hypotension Syndrome

    • EKG Changes


Respiratory changes

Respiratory Changes

  • Hormonal Changes

  • Lung volume changes

  • Difficult Intubations

  • Response to

    volatiles


Uteroplacental circulation

Uteroplacental Circulation

  • At term: uterine blood flow increased

  • UAP-UVP/UVR

  • Factors Decreasing blood flow:

    • 1) hypotension

    • 2) Vasoconstriction

    • 3) Uterine contractions


Pharmacology

Pharmacology

  • Altered drug responses

  • Placental Transfer of drugs

  • Ephedrine and Neosynephrine

  • Local Anesthetics


Prevalence of cesarean births

Prevalence of Cesarean Births

  • Caesarean section rates on the rise

  • Multiple reasons for the drastic increase


Major indications for cesarean section

Major indications for Cesarean section

  • Labor unsafe for mother and fetus

    • Increased risk of uterine rupture

      • Previous classic cesarean section

      • Previous extensive myomectomy or uterine reconstruction

        -Increased risk of maternal hemorrhage

      • Complete or marginal placental previa

      • Placenta abruption

      • Previous vaginal reconstruction


Maternal risks

Maternal Risks

  • Dystocia

  • Increased heart rate or blood pressure

  • HELLP

  • Hemorrhage due to placental and uterine abnormalities

  • Infection

  • Multip

  • Repeat C-section


Fetal complications

Fetal complications

  • Decelerations

  • Macrosomia

  • Fetal scalp pH <7.20

  • Amniotic fluid problems


Immediate or emergent delivery

Immediate or emergent delivery

  • Fetal distress

  • Umbilical cord prolapse

  • Maternal hemorrhage

  • Amnionitis

  • Genital herpes with ruptured membranes

  • Impending maternal death


Fetal monitoring

Fetal Monitoring

  • Baseline fetal heart rate 120-160

  • Decreased vs Increased fetal heart rate

  • Variability


Decelerations

Decelerations


When is the decision made for an emergency c section

When is the decision made for an emergency C-section?

  • Collaborative effort

  • Differences in opinion of appropriate Decision to Delivery Interval (DDI)

  • Increased risk of hemorrhage


Obstetrical emergency

The Royal College of Obstetricians and Gynecologists. Classification of Urgency of Casearean RiskGood Practice (11).


What has to be done between decision to deliver and delivery

What has to be done between decision todeliver and delivery

Informed consent:

  • Consent form signed

    Intravenous access

  • Blood samples to be taken

  • Blood forms to be filled in

  • Bloods to laboratory

  • Intravenous fluids running

  • Premedication to be got from drug cupboard

  • Premedication drawn up

  • Premedication injected

    Anaesthetist informed

  • Operating department assistant informed

  • Consultant to be informed

  • Anaesthetist to arrive

  • Operating department assistant to arrive

  • Intravenous lines to be secured

  • Fetal scalp clip to be removed

Theatre to be set:

  • Scrub nurse to scrub

  • Packs to be opened

  • Sutures to be opened

    Woman to be moved to theatre:

  • Woman to be moved on to theatre table

    Spinal:

  • Spinal drugs to be drawn up

    Monitoring to be attached

  • Spinal anaesthesia

  • Wait for block to work:

    Paediatrician to be present

    Catheter

    Shave

    Surgeons to scrub

  • Skin preparation

  • Skin incision

    Peritoneum opened

    Uterine incision


Indications for general anesthesia

Indications for General Anesthesia

  • Fetal distress without epidural in place

  • Acute maternal hypovolemia

  • Coagulopathy

  • Inadequate regional anesthesia

  • Maternal refusal of regional anesthesia


General anesthesia

General Anesthesia

  • 15% of all C-sections

  • Aspiration risk

  • Attach monitors, place parturient in left uterine displacement, preoxygenate, wait until surgeon is ready to cut.

  • Difficult airway preparation

  • RSI


General anesthesia1

General Anesthesia

  • Agents

    Propofol 2.5mg/kg

    Succinylcholine 1-1.5mg/kg

  • Inhalational Maintenance

  • After delivery medications

  • Extubate Awake!


Frequency of postpartum hemorrhage in maternal mortality

Frequency of Postpartum Hemorrhage in Maternal Mortality

  • 10.5% of all live births are associated with obstetrical hemorrhage.

  • Primary and Secondary hemorrhage

  • 7 year study

  • AMTSL


Placental and uterine abnormalities

Placental and Uterine Abnormalities

  • Antepartum Hemorrhage

    -Placenta Previa

    -Placenta Abruption

    -Uterine Rupture


Obstetrical emergency

  • Post Partum Hemorrhage

    -Accreta, Increta, Percreta

    -Uterine Atony

    -Acute Uterine Inversion


Classification of hemorrhage

Classification of Hemorrhage


Uterotonic medications

Uterotonic Medications

  • Pitocin

  • Ergot Alkaloids

  • Prostaglandins

    Uterine Massage


Prostaglandin f2 alpha

Prostaglandin F2 Alpha

  • Prostaglandin F2 alpha can be given locally or intramyometrially with a recommended dose of 250mcg.

  • Side effects are similar

  • 2000 Cochrane Review


Invasive treatments

Invasive Treatments

  • Retained placenta removal

  • Balloon tamponade

  • Arterial embolization

  • Uterine compression sutures


Fluid resuscitation

Fluid resuscitation

  • Susceptibility of massive blood loss

  • When to transfuse

  • What about crystalloids?

  • Hemorrhagic changes in coagulopathy

  • Cations

  • Cell Salvage


Blood components

Blood Components


Conclusions

Conclusions

  • Identify risks for hemorrhage

  • Be prepared for general anesthesia in all situations

  • Intervene early to reduce complications

  • Effective communications with team members and obstetrician during all emergencies.


Thank you

Thank you!

QUESTIONS??


References

References

  • Borgman MA, Sinella PC, Perkins JG, et al. The ratio of blood products transfused affects mortality in patients receiving massive transfusions at a combat support hospital.

  • Smith JR, Brennan BG. Post partum hemorrhage 2007. Accessed April 9, 2012 from www.emedicine.com/med/topic3568.htm

  • World Health Organization. Attending to 136 million births, every year: make every mother and child count: the world report 2005, Geneva: WHO; 2005.

  • Ahonen J, Stefanovic V, Lassila R. Management of post-partum haemorrhage. ActaAnaesthesiol Scand. 2010;54(10):1164-1178.

  • Akhtar Z, Qazi Q, Khan I. Prostaglandin F2 alpha: An effective alternate to surgical control of postpartum hemorrhage in uterine atony. JPMI: Journal of Postgraduate Medical Institute. 2010;24(1):27-30.

  • CaberoRoura L, Keith LG. Post-partum haemorrhage: Diagnosis, prevention and management. Journal of Maternal-Fetal & Neonatal Medicine. 2009;22:38-45.

  • American College of Obstetricians Gynecologists Optimal goals for anesthesia care in obstetrics. ACOG Committee opinion #256.Washington DC: ACOG; 2001


Obstetrical emergency

  • Fayyaz S, Faiz NR, Rahim R, Fawad K. Frequency of postpartum haemorrhage in maternal mortality in a tertiary care hospital. JPMI: Journal of Postgraduate Medical Institute. 2011;25(3):257-262.

  • Prendiville WJP. Active versus expectant management in the third stage of labour. Cochrane Database of Systematic Reviews. 2010(3).

  • Ahonen J, Jokela R, Korttila K. An open non-randomized study of recombinant actived factor VII in major post-partum hemorrhage. ActaAnaesthesiol Scand 2007; 51: 929-36.

  • Waterstone M, Bewley S, Wolfe C. Incidence and predictors of severe obstetric mobidity: case=control study. Br Med J 2001; 322: 1089-94

  • Charbit B, Mandelbrot L, Samain E, Baron G, Haddaoui B, Keita H, Sibony O, et al. The decrease of fibrinogen is an early predictor of the severity of postpartum hemorrhage. J ThrombostHaemost 2007; 5: 266-73.

  • Borgman MA, Spinella PC, Perkin JG, Grathwohl KW, Repine T, Beekley AC, et al. The ratio of blood produts transfused affects mortality in patients receiving massive transfusions at a combar support hospital. J Trauma 2007; 63: 805-13.

  • Cho JH, Jun HS, Lee CN. Hemostatic suturing technique for uterine bleeding during cesarean delivery. ObstetGynecol 2000; 96: 129-31.

  • Hillemanns P, Hasbargen U, Strauss A, Schulze A, Genzel-Boroviczeny O, Hepp H. Maternal and neonatal morbidity of emergency cesarean sections with a decision to delivery interval under 30 minutes. Arch Gynecol Obstet. 2003;268:136–141.


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