1. Obstetrical Emergency Natalie Collins, BSN

2. Objectives Quick review of normal changes Maternal Abnormalities Risks to the baby Hemorrhage Treatment Resuscitation Guidelines

3. 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

4. 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

5. Respiratory Changes Hormonal Changes Lung volume changes Difficult Intubations Response to volatiles

6. Uteroplacental Circulation At term: uterine blood flow increased UAP-UVP/UVR Factors Decreasing blood flow: 1) hypotension 2) Vasoconstriction 3) Uterine contractions

7. Pharmacology Altered drug responses Placental Transfer of drugs Ephedrine and Neosynephrine Local Anesthetics

8. Prevalence of Cesarean Births Caesarean section rates on the rise Multiple reasons for the drastic increase

9. 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

10. Maternal Risks Dystocia Increased heart rate or blood pressure HELLP Hemorrhage due to placental and uterine abnormalities Infection Multip Repeat C-section

11. Fetal complications Decelerations Macrosomia Fetal scalp pH <7.20 Amniotic fluid problems

12. Immediate or emergent delivery Fetal distress Umbilical cord prolapse Maternal hemorrhage Amnionitis Genital herpes with ruptured membranes Impending maternal death

13. Fetal Monitoring Baseline fetal heart rate 120-160 Decreased vs Increased fetal heart rate Variability

14. Decelerations

15. 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

16. The Royal College of Obstetricians and Gynecologists. Classification of Urgency of Casearean Risk Good Practice (11).

17. What has to be done between decision to deliver 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

18. Indications for General Anesthesia Fetal distress without epidural in place Acute maternal hypovolemia Coagulopathy Inadequate regional anesthesia Maternal refusal of regional anesthesia

19. 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

21. General Anesthesia Agents Propofol 2.5mg/kg Succinylcholine 1-1.5mg/kg Inhalational Maintenance After delivery medications Extubate Awake!

22. 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

23. Placental and Uterine Abnormalities Antepartum Hemorrhage -Placenta Previa -Placenta Abruption -Uterine Rupture

24. Post Partum Hemorrhage -Accreta, Increta, Percreta -Uterine Atony -Acute Uterine Inversion

25. Classification of Hemorrhage ClassBlood Loss (ml)Percentage Lost 190015 21200-150020-25 31800-210030-35 4240040

26. Recognition of PPH Determination of etiology Uterine Atony Uterotonics, uterine massage Balloon tamponade Uterine compression sutures, arterial ligation, hysterectomy Arterial embolization Retained placenta, placental fragments Manual removal, curettage Lacerations, tears, uterine rupture Surgical exploration, laceration repair

27. Uterotonic Medications Pitocin Ergot Alkaloids Prostaglandins Uterine Massage

28. 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

29. Recognition of PPH Determination of etiology Uterine Atony Uterotonics, uterine massage Balloon tamponade Uterine compression sutures, arterial ligation, hysterectomy Arterial embolization Retained placenta, placental fragments Manual removal, curettage Lacerations, tears, uterine rupture Surgical exploration, laceration repair

30. Invasive Treatments Retained placenta removal Balloon tamponade Arterial embolization Uterine compression sutures

31. Fluid resuscitation Susceptibility of massive blood loss When to transfuse What about crystalloids? Hemorrhagic changes in coagulopathy Cations Cell Salvage

32. Blood Components ComponentMin Amount Administe red VolumeEstimated EffectsIndications Packed RBC1 units250-325 ml per unit Each raises 1gm/dl Hg concentration Correct anemia Fresh Frozen Plasma 1 unit in 1 bag 200ml per bag 10-15ml/kgCorrect PT, aPTT Platelets4-6 units of whole blood platelets in 1 bag 200- 250ml per bag Each unit increases 5000- 10,000/ul platelet concentration increases 30,000- 60,000 Correct thrombocytopenia from transfusions or dilutional effects Crypoprecipitate10 pooled units 100- 150ml/10 pool units Each 10 pooled units increases fibrinogen by 70- 100mg/dl Correct hypofibrinogenmia

33. 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.

34. Thank you! QUESTIONS??

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