Precipitous Delivery Review the basic equipment needed for a - PDF document

Objectives  Review the physiology of labor & delivery Precipitous Delivery  Review the basic equipment needed for a successful emergency department delivery Are you prepared?  Manage complications associated with antepartum and intrapartum emergencies Rachel Chin M.D. Associate Professor of Clinical Medicine San Francisco General Hospital UCSF School of Medicine Physiology Physiology  A woman ’ s vital signs change  Heart Rate - increases 15-20 beats/min to an average pulse of 80-95 by 3rd trimester during pregnancy.  Blood Pressure  2nd trimester --> decreases to an avg of  Heart rate increases 102/55  Blood pressure decreases  3rd trimester --> increases to an avg of 108/67 1

Physiology What can possibly go wrong?  Cardiac output increases 40%  PreEclampsia/Eclampsia  Stroke volume increases 25-30%  Vaginal bleeding  Placenta Previa, Abruption  Plasma volume increases 45-50%  Prolapsed cord  RBC mass increases 33% but not as fast as plasma volume  Malpresentation  Physiologic anemia  Breech, Limb, Face delivery  Slight respiratory alkalosis  Meconium staining  Premature delivery Antepartum Emergencies Pre-eclampsia  Hypertension after 24th week of gestation  Pre-eclampsia/Seizures (Eclampsia)  New onset or worsening of chronic HTN  5-7% of pregnancies  Vaginal Bleeding  Most often in first pregnancies  Other risk factors include young mothers, no prenatal care, multiple gestation, lower socioeconomic status 2

Pre-eclampsia Pre-eclampsia  Triad  Etiology?  “ Disease of theories ”  Hypertension  Proteinuria  Abnormal endothelial fxn-cytokines (i.e., tumor necrosis factor  ) and endothelin-1  Edema Preeclampsia-Searching for the Cause N Eng J Med 2004;350(7):641-642 Pre-eclampsia Pre-eclampsia  Signs and Symptoms  Signs and Symptoms  Hypertension  Rapid weight gain  Systolic > 140 mm Hg  >3lbs/wk in 2nd trimester  Diastolic > 90mm Hg  >1lb/wk in 3rd trimester  Decreased urine output  Or SBP > 30 mmHg or DBP > 15mmHg above patient ’ s baseline BP  Headache, blurred vision  Proteinuria  Nausea, vomiting  1 + urine dip or >300 mg in 24 hrs  RUQ or Epigastric pain  Edema (particularly of face) 3

Pre-eclampsia Pre-eclampsia  Complications  Management  Eclampsia  Labor induction if term  Abruption  Consider if pre-term  Premature separation of placenta  Cerebral edema or stroke  Lateral recumbent position  Renal failure  Bedrest  Hemolytic anemia  Lower blood pressure if SBP>170 or DBP>105  Thrombocytopenia  Hepatic hematoma/hepatic failure  Betamethasone if <34wks gestation  Retinal damage  Pulmonary edema  IUGR Eclampsia Eclampsia  Complications  Occurs in less than 1% of pregnancies  Same as pre-eclampsia  Signs, symptoms of pre-eclampsia  Maternal mortality rate: 10% plus:  Fetal mortality rate: 25%  Grand mal seizures  Coma 4

Question 34 year old 35 week pregnant female with  What is the best anti-convulsive treatment no PMH BIBA for seizures. Found down for eclampsia? at home by husband, sz ’ ed twice in the ambulance. C/o HA & epigastric pain  A. IV phenytoin night prior. Paramedic report no head  B. IV diazepam trauma but ecchymosis on chest and  C. IV magnesium sulfate neck. VS: BP 200/116, HR 90, RR 16, 100% NRM, FHT 140 ’ s. What do you do? How should we treat Eclampsia seizures?  Management  Magnesium sulfate > phenytoin or  100% O 2 ; assist ventilations, as needed diazepam  Left lateral recumbent position  MgSO4  6 gm IV bolus, then 2 gm/hr  10 gm IM if no IV access (5gm each buttock) Collaborative Eclampsia Trial  Betamethasone if <34 weeks gestation Lancet 1995 June 10;345:1455-63 5

Magnesium sulfate Magnesium sulfate  Reduces risk of recurrent seizure, maternal  4g IV loading dose over 15 minutes then mortality and neonatal morbidity 1-2 g/hr infusion  Mechanisms: potent vasodilator (against  Maintain serum concentration 4-7 mg/dL vasospasm) and NMDA receptor (when serum level is not readily available, antagonist (neuroprotection) infusion should be titrated to maintain  “ MgSO4 ” now on list of JCAHO-prohibited deep tendon reflexes) abbreviations  Maternal toxicity of magnesium is rare if drug is carefully administered & monitored N Engl J Med 2003;348:2154-2155. Side Effects Your patient has been admitted for eclampsia and is receiving magnesium sulfate at 2gm/hr. You assess that your pt ’ s respirations are 8  Drowsiness per min and you cannot elicit a reflex. What do  Flushing you do?  Diaphoresis  A. Discontinue magnesium & get a neurology  Hyporeflexia consult.  Hypocalcemia  B. Discontinue magnesium and administer O2  C. Discontinue magnesium and give O2 and 1 gm calcium gluconate IV. 6

Toxicity Antidote  Absent DTRs (deep tendon reflexes)  Calcium gluconate  Ataxia  Calcium chloride- greater concentration  Pulmonary edema  Respiratory paralysis Magnesium sulfate Your eclamptic patient is approximately 2 hours out from her seizure. Labor induction is  First warning of toxicity is loss of DTRs (8- progressing successfully with cervix now 6 cm 12 mg/dl) dilated. Her BP has been consistently elevated, with the last 2 readings approx 165/110. Your  Somnolence (10-12 mg/dl) choice for antihypertensive therapy is:  Slurred Speech (10-12 mg/dl)  a. methyldopa (Aldomet) 500mg PO  Muscular paralysis (15-17 mg/dl)  b. hydralazine 5 mg IV  Respiratory difficulty (15-17 mgdl)  c. nifedipine 10 mg PO  Cardiac arrest (30-34 mg/dl)  d. labetalol 20 mg IV Sibai BM, NEJM 1996;335(4):257-265 Treatment of Hypertension in Pregnancy 7

Hydralazine Labetalol  Selective  and nonselective  antagonist  Arterial vasodilator  5 mg IV, then repeat 5 mg IV for 20 min up  20 mg IV, then 40-80 mg IV for 10 minutes to 20 mg total dose to 300 mg total dose  IV infusion 5-10 mg/hr titrated  IV infusion 1-2 mg/min titrated  Must wait 20 min for response between IV  Less reflex tachycardia and hypotension doses; possible maternal hypotension than with hydralazine Abruption Abruption  Signs and Symptoms  Mild to moderate vaginal bleeding Premature separation of  But may have “ concealed ” bleeding at fundus placenta from uterus  Continuous, knife-like abdominal pain  Rigid, tender uterus between contractions High risk groups:  High frequency, low amplitude contractions Older pregnant patients  Signs, symptoms of hypovolemia Hypertensives Multigravidas  Fetal distress Pre-eclampsia Trauma Cocaine 8

Abruption Abruption Hypovolemic shock out of proportion to Third-trimester abdominal pain equals visible bleeding equals Abruption until proven otherwise Abruption until proven otherwise Abruption Placenta  Management Previa  100% O 2  Left lateral recumbent position Implantation of  Supportive care for hypovolemic shock placenta over  OR if fetal distress cervical opening 9

Placenta Previa Placenta Previa  Signs and Symptoms  Management  Bedrest and “ vaginal rest ”  Painless, bright-red vaginal bleeding  Classically after sex/vaginal penetration  If decompensating,  Soft, non-tender uterus  100% O 2  Left lateral recumbent position  Signs and symptoms of hypovolemia (proportional to blood loss)  Supportive care for hypovolemic shock  Cesarean delivery  May cause reflexive contractions ( “ irritability ” )  Betamethasone if <34 weeks gestation  Fetal distress Labor  Define it.  “ It ’ s involuntary uterine contractions that Placenta Previa result in effacement & dilation of the cervix A vaginal exam should NEVER be and actual expulsion of the products of performed on a patient in the 3rd- conception. ” trimester with vaginal bleeding until you know where the placenta is located Rosen et al. 10

Stages of Labor History First Stage:  Is this your 1st baby? Contraction & dilation  When did your water break? Color?  Have you been receiving pre-natal care? Second Stage:  Do you expect any complications? Baby moves  Are you currently taking any prescription through birth canal & is born medication?  Have you been using any drugs or alcohol? Third Stage: Placenta delivered  Do you feel the need to push or have a BM? Imminent Signs of Delivery Delivery  Need to bear down or have a BM  Call for help  “ I need to poop ”  Peds, OB, NICU  Crowning  Warming unit, warm blankets  Rupture of amniotic sac  Contractions  1 to 2 minutes apart  Regular  Lasting 45 to 60 seconds 11

Basic Equipment Basic Equipment  1 dozen 2 ” x 10 ” gauze sponges  Sterile gloves  Surgical scissors-1 pair  Baby blanket-1  Hemostats or cord clamps-3  Sanitary napkins  Small rubber bulb syringe  Plastic bag  Towels-5 Delivery Delivery  Place gloved hand on • Control head and presenting part to prevent “ explosive ” support perineum • Slight downward delivery pressure to decrease pressure on urethra 12