1. OBSTETRICAL EMERGENCIES
Kathleen Murray, CNM, MN, RN Larry Whorley, BSN

2. 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.

3. 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?
Important to know what each of these are, and the emergency steps the nursing team should perform to care for patient. In some cases, your care can turn an emergency situation into a healthy outcome for mom and baby.

4. Placenta Previa Poor site chosen by zygote at implantation
Can be complete, partial, or marginal
Easy to see on US, often diagnosed 1st trimester and followed thru pregnancy, spotting is common. Not dangerous until labor and dilation of cervix. Is not usually an emergency, not covered today, but wanted to remind you of what it is. Now, let’s talk about a related problem that IS an emergency.

5. 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
ASK: What does “vasa previa” mean? Answer: umbilical vessels across cervix in front of baby. Starts with velamentous insertion. Velamentous vessels are unprotected, no cord & Wharton’s jelly to cushion them from compression or tearing.

6. Velamentous Insertion
Associated with earlier placenta previa which moved higher
Photo is Velamentous insertion….
Notice the naked unprotected vessels traveling across the membranes before they reach the umbilical cord. This is called a velamentous insertion of the cord. If the membranes rupture in this spot, the baby will bleed out in a few minutes. If the placenta and cord insertion are all up in the fundus, it will probably turn out fine. But if the vessels are across the cervix, (which would be a ‘vasa previa’), a rupture of membranes will be fatal for baby.

7. In this picture, vessels leave placenta, travel thru sac across cervix, before going into the cord, which is not shown. The vessels are in front of the presenting part, with no cord or Wharton’s jelly to protect them from pressure or from rupture.

8. 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 %
ASK: Why do some placentas end up as previa’s? Answer: Prior c/s scar makes blastocyst hunt for decent place to implant, twins have to compete for space for placenta’s, smokers have damaged vessels in the uterus, not as many good implantation sites. . ASK: why do you think the low-lying placenta makes a vasa previa happen? The answer is coming up.

9. 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
Upper uterus is more vascular, better blood supply. When you have a low placenta: Like a plant leaning toward sunlight, placenta grows upward, bottom disintegrates. Leaves cord in place, which gradually is shifted from center to edge. If extreme, placenta leaves vessels trailing past edge. Velamentous insertion of vessels is one step further than a marginal insertion of cord.

10. This photo shows 1)a bi-lobed placenta, 2)marginal insertion of cord, and 3)velamentous vessels. Velamentous insertions occur often when the placenta is bi-lobed, or has a succenturiate lobe (satellite lobe of main placenta).
(Lijoi, 2003)

11. Diagnosis Antepartum Difficult to diagnosis
Transvaginal sonography with color doppler
(Photo of this US next slide). All women with known bi-lobed placentas, and probably those with twins, etc. should be screened for vasa previa. Vasa previa MUST be discovered before ROM so C-section can be done to save the fetus.

12. Color doppler US involves assigning colors to different blood flows on the US screen, so they can see mom vs. baby, and vein vs. arterial flow, to be able to see where the cord and the vessels are on the screen.

13. 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.
How will you discover vasa previa during labor? Usually no warning.

14. Vasa Previa Obstetrical emergency
Catastrophic implications for the fetus
Fetal outcome based on quick diagnosis, an emergency cesarean and infant resuscitation capability
Even with a crash C-section, it would be hard to be fast enough.

15. Treatment Antepartum Diagnosis Intrapartum Scheduled Cesarean Section
Emergency Cesarean Section
Prepare for full infant resuscitation
All women with known bi-lobed placentas, and probably those with twins, etc. should be screened for vasa previa. If your patient tells you she had a placenta previa earlier in pregnancy, talk to the provider about whether the US looked for velamentous vessels.

16. Now lets look at abruption, which is a different placental problem
Now lets look at abruption, which is a different placental problem. Look at this placenta, with it’s very-healthy attachment to the uterus. ASK: How does the placenta attach? Answer: villi from the placenta, like the hooks in velcro, with spiral arteries in the mom’s endometrium providing a good flow of oxygenated blood in the millions of tiny special capillaries.

17. Abruptio Placentae
Definition: premature separation of the placenta (part or all) from the uterus
Usually after 20 weeks
Premature separation of the placenta accounts for about 15% of all neonatal deaths.
(Neonatal causes of death: 50% due to preterm birth; other causes include intrauterine hypoxia and asphyxia).

18. Classification of Detachment
Grade 0 – approx 250ml (<10% surface)
Grade ml blood(10-20%)
Grade 2 – cc (20-50%)
Grade 3 – >1000cc (>50%)
Approximately half of abruptions are grade 0 or 1 (Gilbert & Harmon, 2003). (hold up placenta-cord model, show edge folded up) This is a small part of the placenta involved, symptoms are mild. Most babies and placentas can compensate for small abruption, but Grade 2 and 3 is when baby’s life really threatened. Grade 3 involves more than ½ of the placenta, and DIC will always happen then also.
Who is bleeding??? Mom, mainly. But, baby gets less oxygen because of disruption of placental attachment.

19. 1st picture shows partial abruption, with bleeding evident
1st picture shows partial abruption, with bleeding evident. Most abruptions are from margin, and have some vag. bleeding, to warn us, fortunately. The 2nd and 3rd pictures show silent (hidden) abruption.

20. Incidence Occurs in 1/120 deliveries 12% of stillbirths R/T abruption
1 in 8 recurrence rate
Abruption happens more often than we realize, about 1 in 120 deliveries. ( Frequency of abruption causing death is 1 in 1420).
Abruptio placentae has become the leading known cause of fetal death.
Even if the infant survives, there may be adverse sequelae—14% are later found to have significant neurological deficits within the first year of life.

21. 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
By far the most commonly associated condition is some type of hypertension. 50% of abruptions severe enough to cause death are associated with hypertension.
Hypertensive women were also more likely to suffer a more severe abruption.
Smoking causes 40% of all abruptions: vasoconstriction of spiral arterioles,& necrosis. Is Dose – dependent.
Cocaine: vasoconstriction, high BP
Prior history: hx 1 abruption = 10% chance repeat, hx 2 abruptions = 25% chance repeat.
Uterine abnormalities such as bicornate or didelphys (double) uterus causes abnormal surface to attach to.
Uterine fibroids (leiomyoma) located behind the placenta predispose to abruption.
Short cord, sudden uterine decompression as in second twin or in polyhydramnios may be additional factors. 5% risk abruption after preterm PROM.

22. 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
Bleeding: Port wine-colored amniotic fluid is an indicator of a premature separation of the placenta. Bldg dark because has had time to begin clotting. Remember: there is concealed bleeding in 20% of cases.
Shock: increase pulse, decrease BP, pale, clammy skin, N & V
Uterine little, frequent irritable-type contractions, hypertonus may be present
Couvelaire uterus—The condition in which blood is forced into the uterine musculature. Causes pain, rigidity, irritability. This acute condition may be associated with DIC (disseminated intravascular coagulation) and may require a hysterectomy. Placental fragments (thromboplastin) forced into maternal circulation, causing widespread little clots in mom’s body. Will talk more about DIC later.
FHR—Decreased variability, late decelerations, baseline changes, sinusoidal pattern. Fetal death occurs when 50% or more of blood volume from placenta is lost
Other symptoms: anxiety, fear, confusion

23. Lab Findings Decreased H&H Decreased coag factors
Presence of fetal-to-maternal bleeding (detected by Kleihauer-Betke test)
APT test (a alkaline denaturation tests)—done on blood collected on chux to determine if it is fetal or maternal. If fetal, it means the blood is coming from the placenta abruption.
Coagulation tests: (PT, PTT, platelet count, D-dimer (may be 2 times higher than normal), fibrinogen, FSP) because retroplacental clot uses up clotting factors
Kleihauer-Betke tests for fetal cells in maternal serum. Very small volumes of blood cells commonly escape from the fetal intravascular compartment across the placental barrier into the maternal intervillous space. Large hemorrhages are uncommon. 30 ml of fetal blood into maternal circulation would be large.
This test often done in blood bank and can take one technician 1-2 hours to complete it. Answer sometimes confirms Dx after delivery has already happened, might help nursery determine whether to give baby a transfusion, might also help determine Rhogam dose for mom if she is Rh neg.

24. Diagnosis and Medical Management
Patient history
Physical exam
Lab studies
Ultrasound
Treatment depends on severity of abruption
Exam of placenta at delivery confirms
History:BP/trauma/pain/bldg,etc. PE including palpation of uterus for pain and rigid tone. Labs (H&H,clot studies, Klei-hauer-Betke).
Ultrasound can be unreliable; only about 25-30% of cases confirmed by identifying a intrauterine clot. It is not usually used for diagnosis.
Abruptions are classified as marginal (only the margin of the placenta is involved), partial, or total (complete).
Exam at del, look for adherent clot. Placenta to pathology for study.

25. 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
O2 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)
Crystalloids or colloids: Ringer’s lactate, or Plasmanate if in shock.
Fetal scalp electrode can carry mom’s HR thru dead fetus, verify whose HR you are monitoring!!! ASK: how do you know whose HR you’ve got?

26. 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
Fluid and blood might be given to maintain hct of 30%.

27. Only go thru next slide with them (need to un-hide it) if not going to play Kathleen’s game after covering Uterine Rupture

28. Compare and Contrast Abruptio Placentae Placenta Previa
Blood Color
Pain
Uterine Tenderness
Uterine Tone
Shock
DIC
Ultrasound
Fetal Distress
Usual Characteristics of Placenta Previa vs. Abruptio Placentae: Exercise for students
Abruptio Placentae Placenta Previa
Blood: dark red, clots bright red
Pain: painful—constant painless (unless in labor)
Tenderness:usually present absent
Tone: increased, may feel tense, rigid normal
Shock: frequent, esp. with severe grades uncommon
DIC: frequent, esp. with severe grades very rare
U/S: appearance of clots behind placenta determines placenta may not be clots; actual clots hard to location
identify
F/distress: frequent, esp. with severe grades rare, unless maternal shock or significant
fetal blood loss
Signs and symptoms may vary from the above classical characteristics.

29. 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
The terms uterine rupture and uterine dehiscence are sometimes used interchangeably in literature.
In dehiscence the fetus remains inside the uterus, the scar is not broken all the way thru.
. Excessive bleeding usually occurs with uterine rupture, whereas bleeding is generally minimal with dehiscence (scar tissue does not have blood vessels).

30. 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)
True uterine rupture is exceedingly rare as above. Usually in labor, may occur spontaneously without risk factors.
Dehiscence occurs slightly more often. Near-dehiscence or thinning of the scar is referred to as the “window” through the scar that might be seen when doing a C-section.

31. 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
Uterine rupture occurs most frequently in women with a previous uterine incision through the myometrium (muscle). Classical incision is considered to be the highest risk for rupture. Vertical incision, weak healing of scar, stretched again by pregnancy.
Hyperstimulation or hypertonus of the uterus by oxytocin, or chemical weakening from prostaglandin administration can cause uterine rupture. Cytotec contraindicated.
Invasive or blunt trauma as seen in women after a MVA, dom. violence, fall or with a gunshot wound.

32. Clinical Manifestations
Sudden fetal distress
Abdominal pain
Syncope, pallor, vomiting, shock
Maternal tachycardia
Vaginal bleeding
Presenting part ascent
The clinical picture may develop over several hours, with the woman complaining of the above symptoms.
Uterine contractions usually continue.
The most common sign of rupture is a non-reassuring FHR tracing—fetal bradycardia.
The pain of uterine rupture usually overcomes an epidural (is not hidden by it).
Bleeding can quickly cause maternal hypotension and shock.
An inability to reach the presenting part on vaginal exam after having reached previously.
Fetal parts may be felt through the abdomen outside the uterus.
Anxiety and fear may be expressed by mother, knowing that something is wrong.
Bleeding may be vaginal or intra-abdominal. Intra-abdominal bleeding may radiate pain to the shoulders.
Dehiscence of a prior lower segment cesarean scar is usually asymptomatic.

33. 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
Who will you call?? Ob doctor, anesthesia, extra RN’s to care for patient, nursery, etc.
Besides the physical things needed to address this emergency, remember the emotional needs of the patient and significant other. Fear and anxiety will be present. Inform patient of procedures and reassure her you will stay with her.

34. 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
Uterine rupture nearly triples for women with a history of more than two prior low-transverse cesarean births.
Provider must be surgeon (not CNM or family practice doctor) and stay in house even in early phase of labor.
The fact that a mom had a C/S years ago for breech, and then had 3 VBAC’s does NOT make her low-risk for rupture. In fact,
the subsequent pregnancies thinned out her uterus and make her MORE at risk of rupture. The BEST Vbac is with
a mom who had ONE C-section for breech or fetal distress (not CPD) and one previous vaginal birth.

35. Stop here to play Kathleen’s game for nurses about Vaginal Bleeding s/s

36. 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
Hypersensitivity or anaphylactic reaction to fetal antigens may be present.
Primary finding is severe pulmonary arterial vasospasm as a result of amniotic fluid entering the lungs, followed by severe non-cardiogenic pulmonary edema.
Also is called anaphylactoid syndrome of pregnancy. This is because studies indicate some women with fetal cell material in their circulation are fine (no s/s), and that women with AFE seem to have allergic reaction to fetal cells in their circulation.

37. 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
Extremely rare. Many providers do not see one in their entire career.
Statistics Gilbert & Harmon, 2003;also Schoening, A, Am J Mat-Child Nsg, Mar 06
For 75 years we have thought was simply a matter of embolus of amniotic fluid entering maternal circulation, fetal hair/cells/meconium blocking pulmonary blood vessels, etc. Recent work suggests is a catastrophic immune over-reaction to fetal cells in circulation.

38. 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
Mimics anaphylaxis and sepsis.

39. 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
Detection of fetal squamous cells, hair, lanugo, and mucin in maternal blood has been the cornerstone for diagnosis, with many cases diagnosed at autopsy. Several clinicians have reported finding fetal squamous cells in blood aspirated from the pulmonary artery in patients without symptoms. And some women with AFE s/s did not have fetal cells detected in circulation.
There are no data that any type of intervention improves maternal prognosis with amnionic fluid embolism (Williams 21st ed.) This is still true. Antihistamines have been tried don’t seem to help. Basically, you deliver them, do CPR, and give blood and they go to ICU.

40. 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
Here is a list of the steps you’d be involved with. With the family members, we often don’t kick everyone out of the room any longer during CPR, etc., because people deal with loss better if they KNOW we did everything we could. This is obviously a judgement call. You should anticipate grieving and call pastoral care, social worker, manager of your unit, etc. Luckily, as we said, you are not likely to see this occur in your career. Hopefully, medical science will develop better ways to predict, prevent, treat this problem.

41. Disseminated Intravascular Coagulation
What does DIC stand for?
Answer: death is coming.
Is a true crisis, the patient is bleeding uncontrollably.
High mortality rate, rapid coordinated response of team important.

42. DEFINITION DIC: small blood clots develop throughout the bloodstream
Blocking all blood vessels
Using up all the clotting factors
DIC is not a disease, but an event, caused by an illness or other severe problem that sets it in motion. Does it happen only in L&D? NO, it can happen to a 20 year old man in ICU with Sepsis!

43. 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
There is a cascade of events in DIC leading to massive hemorrhage.

44. DIC triggers in pregnancy
Placental abruption
HELLP syndrome
Sepsis
Retained IUFD
Amniotic fluid embolus
IUFD is intra-uterine fetal demise

45. 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
Bleeds from gums, from previous venipuncture site from days ago…
Typical shock symptoms on next slide

46. Physiological Signs Easily bruises IV Site bleeding
Abnormal vaginal bleeding
ROM- large blood loss
Tachycardia
Hypotension
Decreased urinary output
FHR- Tachy then Bradycardia
Patient shows S/s of shock.

47. Testing- LAB WORK FDP- HIGH levels PT-HIGH PTT- HIGH
Bleeding times- INCREASED
Serum Fibrinogen- LOW
Platelets- LOW
H.E.L.L.P. Syndrome
FDP is fibrin degradation products PT is protime….bleeding time

48. TREATMENT IMMEDIATE DELIVERY- CRASH C/S 16 gauge IV Oxygen
Right hip roll until delivered, etc.
Transfusion blood products
Transport to ICU
Empty the uterus to correct initial cause of DIC. Delivery of placenta causes shift in process, with fibrinogen levels rising immediately, usually condition improves within few hours, (as far as clotting abnormality process).
Give packed RBC’s, fresh frozen plasma (contains fibrinogen), cryoprecipitate (clotting factors), and platelets.
Often need two teams. One perinatal, and one trauma/critical care response. Real concern after DIC is stopped, is looking for organ damage from all the little clots (kidney damage common, etc).

49. 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
OK, now let’s talk about something you can almost always do something to save the day!!!
Review slide.
The cord Can extend through the vaginal opening
Can be felt at the cervical opening
Can be occult or hidden

50. The pictures show different degrees of prolapse
The pictures show different degrees of prolapse. Look at the last one, of the breech baby. (show doll in breech position with cord attached…) ASK: why do breeches have prolapse more often?? Answer: poorly fitting presenting part allows it to slip down, and also cord attachment at low-lying navel predisposes it to drop.

51. Etiology Potential hazard of ROM Contributing factors: Long cord
Malpresentation or unengaged presenting part
Breech presentation
Prolapse can happen with ANY ROM, but especially likely with AROM when head is not into pelvis. Is actually rare in SROM. The risk of prolapse, which might only be known thru EFM, is the reason the doctor or CNM needs the nurse in the room when doing an AROM.

52. Diagnosis Variable decelerations during uterine contractions
Fetal bradycardia
Cord felt or seen protruding from vagina
If your patient had AROM 15 minutes ago , and starts to have variable decels now, go check her again!

53. 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
To hold presenting part away from the cord, the examiner may have to put counter pressure on the presenting part until delivery—ride on the bed to C/S room, under drapes, etc.
Reposition patient to reduce compression of the cord by the presenting part—Trendelenburg, knee-chest.
Handling cord can cause the cord to spasm, shutting off the fetal blood supply.
If the cord extends through the vagina, cover it with a sterile gauze pad moistened with saline solution to keep it from drying out.
Call care provider at the slightest suspicion of a prolapsed cord.

54. Actually, all cases I have seen involved putting mom in knee-chest position, to get best possible relief of pressure-off-cord, until surgeon and anesthesia and everyone else ready to go…..fast general while quick prep, and cut. Nurse under drape whole time holding head up.

55. Fetal Outcomes
With prompt recognition & rapid delivery fetal outcome is excellent
Unrelieved cord compression >5min
risk of significant CNS damage and
fetal death
Cord prolapse makes the nurse have a heart rate of about 150, but the outcomes are usually good because there is a lot you can do to keep the baby safe.

56. Precipitous Labor and Delivery
Kathleen Murray, CNM, MN
Lori Valentine, RNC

57. Objectives Define precipitous labor and delivery
Discuss the nursing management of a precipitous labor and delivery.

58. 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.

59. Signs and Symptoms May display extreme agitation and discomfort
Or, may be comfortable
Increase in bloody show,
grunting , spontaneous pushing
How do you know your patient is going to deliver quickly?

60. 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!!

61. Complications Uterine rupture Pelvic tissue trauma Fetal hypoxia
Fetal head trauma
Erb’s palsy
Complications are actually rare with precip births. (move immediately into next slides which explain the complications).

62. Uterine Rupture
Tumultuous labor with abnormally strong uterine contractions and a firm closed cervix
Spontaneous rupture of the uterus from a hard fast labor is very rare, more likely with preterm when cervix is not ripe, or when we are giving too much pitocin!!!!.

63. Pelvic Tissue Trauma
3rd or 4th degree laceration involving the perineal body and anal sphincter
Cervical laceration
Urethral laceration
Actually, 3rd and 4th degree tears are almost always due to an episiotomy, not to the nurse delivering a baby.

64. Fetal Hypoxia
Vigorous labor low fetal oxygenation due to poor placental perfusion
Increased risk of meconium
Increased risk for an acidotic newborn requiring resuscitation
What will you ask the other nurse in the room to do if you are busy catching a precip baby??? Answer: she should get supplies ready to resuscitate the baby because sometimes the baby is overwhelmed by the rapid birth.

65. Fetal Head Trauma
Resistance of the birth canal to expulsion of the head, causing intracranial trauma
ASK: This is most likely with which babies??? Answer: preterm.

66. Erb’s Palsy
Injury of the brachial plexus affecting the nerves that control the muscles of the arm and hand
This is like the injury that occurs with shoulder dystocia, in this case it’s not from being stuck in the birth canal, it’s from the shoulder dragging against the pubic bones real fast as the baby comes shooting out. Kind of like a whiplash injury~!

67. 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
You aren’t ‘supposed’ to have to deliver the babies, but sometimes it’s going to happen!! Your primary responsibilities are to addess mom and baby, see the signs of impending birth and notify the provider promptly so they have a chance to make it to the hospital in time.
your documentation needs to include what you concluded, and who and when you called for help, and what the events were at birth.

68. 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
You might worry about being blamed for a precip. It is your job to do the normal nurse things (oxygen, IV, positioning, etc based on condition), and to recognize risk of precip, to call for help in time. That’s all you are expected to be skilled at.

69. Nursing Interventions
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.
If you DO need to deliver a precipitous baby: (slide) don’t tell them it’s your first time (until it’s over!); call for lots of experienced help!

70. Management and Nursing Care
Precipitous birth kit
Need cord clamps, scissors, & bulb syringe
Call for more nurses
If time permits, scrub/glove/drape

71. Positioning Leave bed intact!
Relieves the nurse from worrying about catching a slippery baby
Side-lying position can slow descent
Leaving the bed unbroken is safer for the baby, and the patient and family will worry less ALSO about the baby falling!

72. Delivery in Vertex Presentation
Gentle pressure with fingers against the fetal skull
Don’t hold baby in!
Put your hands on the head as it emerges. No pressure on the neck, just hold the bony skull. The head comes out flexed, with the crown (top-back) of head coming first. Place a hand on head and another underneath on the perineum. You don’t have to do anything special there. Once the head is born, you might see external rotation take place, when the neck unwinds and the baby’s face turns toward mom’s thigh.

73. 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
Will demo with mannequin

74. 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)
Anterior shoulder will be past the symphysis before delivery of the posterior shoulder

75. Vertex Delivery Suction mouth and nose prn Clamp & cut cord
Baby onto maternal abdomen. Provide tactile stimulation/dry off with warm towels and cover
Cutting the cord is not emergency unless you need to do CPR on the baby!!!

76. 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
How would you know your patient’s baby is breech? Answer: might have history of it (planning C-Section). Otherwise, you discover it during a vag exam or when she’s pushing (if you really want to live on the wild side of life!!). Sometimes hard to feel, butts can be bony. Might see what you think is Head…. Wait, no hair, cleft down center, genitals, squirting stream of mec out of an orifice… all clues.

77. 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

78. 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

79. 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
Follow the usual NRP guidelines about assessing your baby. Expect that the legs won’t lay down for a few hours. Baby stays with mom if possible, just like with other births.

80. Maternal History in Precip Birth
If uncertain pregnancy history, assess gestational age using the Ballard scoring system.
Illicit drug use?
Ballard score uses physical and neurological signs to assess gestational development. Accurate within 2 weeks, plus or minus.
ID infants at risk for hypoglycemia, respiratory distress. Is the baby pink but sleepy, with respiratory depression?? Don’t give Narcan to a baby if mom is suspected narcotic addict, risk of seizures from abrupt withdrawal for baby. It’s better to just keep bagging them.

81. 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
How long does it take for a placenta to be born? A few minutes, to 30 or so.
What’s the biggest cause of PPH? Answer: the jerk on the end of the cord!!! Don’t pull on it unless it’s coming easily!!
If you’re guiding by pulling on cord, remember to put other hand above symphysis and guard the uterus from inverting, just like you do when you do fundal massage in a postpartum patient.

82. Delivery of Placenta
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

83. Vaginal Delivery Practice
using mannequins in room

84. 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. 2010
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