1 / 32

Obstetrical Pearls

2. OB Emergencies. Postpartum HemorrhageEcclampsiaNon Reassuring FHR/ DistressShoulder DystociaUterine inversionPlacental AbruptionBreechRuptured uterus. 3. Postpartum Hemorrhage. Causes- Retained placenta, lacerations, Atony, InfectionIdentify the cause if ableEmpty clots and placenta from

trula
Download Presentation

Obstetrical Pearls

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

    1. 1 Obstetrical Pearls Acer_user

    2. 2 OB Emergencies Postpartum Hemorrhage Ecclampsia Non Reassuring FHR/ Distress Shoulder Dystocia Uterine inversion Placental Abruption Breech Ruptured uterus

    3. 3 Postpartum Hemorrhage Causes- Retained placenta, lacerations, Atony, Infection Identify the cause if able Empty clots and placenta from uterus Start second line large bore IV If lacerations repair them( may need general anesthesia in some)

    4. 4 Management of PP hemorrhage Pitocin 10-40 units per liter of IV fluid (antidiuretic effect, Hypotension if given IV push, it can be given IM) Methergine 0.2mg IM (not to be given IV can cause severe hypertension) Prostaglandin E2 supp 20mg rectally

    5. 5 Management of PP Hemorrhage Prostaglandin F2 alpha 250 micrograms IM (Hemabate) Cytotec 200-400 micrograms D&C Uterine packing Hypogastric artery ligation Hysterectomy Replace clotting factors with FFP 1 units for every 4 of PRBC

    6. 6 Ecclampsia The occurrence of convulsions in a patient that meets the criteria for preeclampsia and no other neurologic reason for seizure HTN, Proteinuria, edema Incidence 1/700-1/1000 pregnancies 1/3 of seizures occur PP

    7. 7 Ecclampsia Treatment Best treatment is prophylaxis with MgSO4 MgSO4 bolus 4-6grams run at 1-3grams/hr If still seizing after initial bolus rebolus with 4 grams If no IV access MgSO4 10grams IM

    8. 8 Ecclampsia Treatment If already on MgSO4 check level and bolus Sodium Amobarbital 250mg IV slowly (may need to intubate) Last resort Diazapam 5-10mg slow IV or Phenytoin but needs to be on cardiac monitor Both can severely sedate mom and baby

    9. 9 Non Reassuring FHR/ Fetal distress Over diagnosed Normal fetal heart rate with an episode of bradycardia usually can undergo intrauterine resuscitation ( make sure no tetanic contractions) Poor tracing with episode of bradycardia is much more serious

    10. 10 Non Reassuring FHR Persistent late decelerations Loss of variability Tachycardia Deep or Severe variable decelerations No response the fetal scalp stimulation

    11. 11 Intrauterine resuscitation IV fluid bolus Reposition the patient If hypotensive give ephedrine Stop Oxytocin +/- Brethine SQ Check cervix O2 with rebreather mask Fetal scalp electrode

    12. 12 Non Reassuring FHR If close to delivery attempt vaginal delivery (faster) If remote from delivery prepare for Cesarean Section-

    13. 13 Shoulder Dystocia Unpredictable event 1%-4% of pregnancies Risk factors- DM, Macrosomia (poor predictors) Less than 10% of shoulder dystocias result in permanent brachial plexus injury

    14. 14 Management of Shoulder Dystocia No Fundal pressure McRoberts Maneuver- Flex mothers legs up to abdomen Suprapubic pressure Woods Corkscrew Maneuver Delivery of Posterior shoulder Zavenelli Maneuver Always get help!

    15. 15 Uterine Inversion Usually iatrogenic occasionally spontaneous Contributing factors are accretas, excessive traction on the cord Hypotensive shock out of proportion to blood loss May be partial or complete inversion

    16. 16 Treatment of Uterine inversion Get help Anesthesiology If able reinvert the uterus with a hand Usually leave placenta attached 2 Large bore IV lines with LR, blood if needed Halothane or MgSO4

    17. 17 Treatment of uterine inversion Once reinverted start oxytocin, methergine, prostaglandins, and stop any uterine relaxants Rare cases laparotomy with combined vaginal replacement

    18. 18 Placental abruption Associated incidents- Trauma, HTN, Preeclampsia, eclampsia, cocaine, cigarettes (Recurrence rate 1/18) Frequency1/85 deliveries Consumptive coagulopathy can result PT, PTT, Fibrinogen, FSP, CBC and platelets

    19. 19 Management of Placental Abruptions 2 large bore IV Blood products Usually Cesarean Section These can be concealed so have a high index of suspicion Ultrasound- need a 30% abruption to be seen Avoid vasodilators

    20. 20 Breech Only a true emergency if delivery is immanent Best if frank or complete breech Do not apply traction to the body just support the body and allow mother to push If able keep the head flexed Suprapubic pressure on occasion

    21. 21 Ruptured Uterus Associated conditions- previous uterine surgery, trauma, grand multiparas, Uterine anomolies (very rare in primagravidas) Signs –abdominal pain,tenderness, shock, vaginal bleeding, Cessation of labor, fetal death Most case do not occur in labor

    22. 22 Ruptured uterus Do not attempt vaginal delivery Immediate surgery C/S, hysterotomy, hysterectomy Type and cross for 6 u PRBC Rupture may take place with a vaginal delivery

    23. 23 Why give antenatal steroids? Decrease incidence or respiratory distress syndrome Decreased incidence or intraventricular hemorrhage Decreased neonatal mortality Decreased neonatal morbidity

    24. 24 Who gets Steroids? Patients with preterm labor that threaten to deliver At least 24 weeks (for PTL) up to 34 weeks Preterm rupture of membranes 24-32 weeks Betamethasone 12mg IM q 24 (2 doses) Dexamethasone 6mg q 12 X 4

    25. 25 Down side of antenatal steroid use If chorioamnionitis is present can worsen maternal and fetal conditions #1 side effect is pulmonary edema (especially if used with tocolytics) Increases contractions Elevates blood sugars Multiple doses have unknown long term effects (1 rescue dose)

    26. 26 Preterm Labor Causes Unknown Infection Uterine anomolies Over distension (multiple births, macrosomia, polyhydramnios) Trauma Abruption

    27. 27 Causes of Preterm Labor Anemia Hypoxia to the uterus

    28. 28 Evaluation of patients with preterm labor History and Physical Vaginal cultures GC, Chlamydia, BV Fetal Fibronectin if negative 95% chance of not delivering in the next 14 days. If positive the correlation to delivery is poor Cervical length less than 2.5cm

    29. 29 Evaluation of Patients with preterm labor Limited digital pelvic exams Tocodynomometer CBC, UA +/- culture, U/S

    30. 30 Treatment for preterm labor No scientific proof anything works Hydration and bed rest Treat infections MgSO4 (4-6gm bolus+ 1-4gm/hr) Terbutaline 0.25 SQ, 2.5-5mg po Ritodrine Indocin (less than 32 weeks) Nifedipine

    31. 31 Review Get help Any patient can turn into a catastrophe Try not to panic Nurses have been through it before

    32. 32 L&D orientation If you want to do D&C’s watch the OR schedule If you are the resident on a case that goes to C/S you are expected to scrub 7:30 morning lecture M-F Don’t be late

    33. 33 Orientation to L&D If you aren’t sure ask! Be persistent when asking for help Nurse can be part of your education Don’t worry about bothering an attending Don’t be hard to find Help out Don’t pass the tough stuff off to the OB/GYN residents Never lie

More Related