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 %
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
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 ml blood(10-20%) Grade 2 – cc (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 O 2 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 mL/hour Explain status and answer questions straightforwardly to allay anxiety Position for comfort Anticipate grieving
Only go thru next slide with them (need to un-hide it) if not going to play Kathleen’s game after covering Uterine Rupture
Compare and Contrast Abruptio Placentae Placenta Previa Blood Color Pain Uterine Tenderness Uterine Tone Shock DIC Ultrasound Fetal Distress
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
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
D isseminated I ntravascular C oagulation
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
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!!
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
Vaginal Delivery Practice using mannequins in room
References OB 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 Perry, S. et al, Maternal Child Nursing Care, 4th ed., 2010, Mosby Elsevier International Vasa Previa Foundation, Lijoi, A, Brady, J, JAHFD, Nov 2003, Vol 16, Number 6, pp Martin, EJ, Intrapartum Management Modules, 4th ed. 2010, Lippincott Mattson, S, Smith, JE, Core Curriculum for Maternal-Newborn Nursing 4th ed. 2011, AWHONN