Obstetric Emergencies



Obstetric Emergencies


Suzanne McMurtry Baird

Betsy Babb Kennedy







Introduction

Intrapartum emergencies are rare, but can be associated with significant maternal and fetal morbidity and mortality. It is important to know how to respond rapidly and appropriately. This module reviews selected issues and nursing care associated with emergencies in the intrapartum period, including cord prolapse, shoulder dystocia, amniotic fluid embolism (AFE), and hemorrhagic complications such as placental abruption, uterine rupture, vasa previa, and immediate postpartum hemorrhage (PPH). Other intrapartum emergencies such as a category III electronic fetal monitor strip (see Module 7), and eclamptic seizure (see Module 11) are presented in other modules. Simulation of potential obstetric emergencies is helpful to proactively assess systems, processes, communication, collaboration, and team member roles. If an obstetric emergency occurs, a debrief session is helpful to organize timing of event, management, and personnel involved. In addition, this discussion allows for all team members to discuss what went well and improvement opportunities.


Prolapsed Cord

Umbilical cord prolapse (UCP) may occur any time the maternal pelvis is not completely filled by the presenting fetal part. It occurs most often in fetal malpresentation, breech or transverse lie, or when the presenting part is not engaged. The most common cause of UCP is rupture of membranes, either spontaneously or artificially.1 The umbilical cord can also prolapse as a result of obstetrical manipulation such as attempted rotation of the fetal head, external cephalic version, amnioinfusion, or placement of a cervical ripening balloon catheter, intrauterine pressure catheter, or fetal scalp electrode.1 Other described risk factors for UCP include malpresentation, fetal anomalies, intrauterine growth restriction (IUGR), cord abnormalities, preterm labor/delivery, preterm premature rupture of membranes, multiple gestation, polyhydramnios, and grand multiparity.1

NOTE: A prolapsed cord means that the umbilical cord lies beside or below the presenting part of the fetus. The estimated occurrence rate is between 1.4% and 6.2% per 1,000 pregnancies.2

A prolapsed cord can:



  • Pass through the cervix either before or alongside of the presenting part (overt; Fig. 16.1)


  • Be palpable at the cervix (funic presentation; Fig. 16.2)


  • Be hidden and not palpable (occult; Fig. 16.3)






FIGURE 16.1 Prolapse of cord through the vaginal opening.






FIGURE 16.2 Prolapsed cord can be felt at the cervical opening.






FIGURE 16.3 Hidden prolapsed cord.

NOTE: In fetal malpresentation, a cervical examination may be performed to evaluate for the presence of a prolapsed cord if membranes rupture spontaneously and a change in the fetal heart rate pattern occurs.


NOTE: Prompt recognition and management of UCP can minimize the effects of fetal hypoxia due to cord compression.

If a UCP occurs, the fetal heart rate monitor may demonstrate abnormal findings such as bradycardia or persistent variable decelerations.




  • Notify a provider who has surgical privileges.


  • Call for help.


  • Place the woman in a position that uses gravity to reduce compression of the cord by the presenting part (Fig. 16.4A, B).


  • If a cord is felt, prepare the woman for an emergent cesarean birth. In rare circumstances, the physician may determine that vaginal birth may be more expeditious than cesarean if the woman is fully dilated and the presenting part has descended.


  • Perform a sterile-gloved vaginal examination. Place two fingers on either side of the cord or both fingers on one side of the cord to avoid compressing the cord and exert upward pressure against the presenting part to relieve pressure on the cord. Maintain elevation of the presenting part off the cord.


  • Try not to handle the cord because it can cause the cord to spasm, further impairing fetal blood supply.3 If the cord protrudes outside of the vagina, replace cord into the vaginal vault with wet gauze if waiting for team arrival for emergent cesarean birth.1


  • Transport the woman to the operating room (OR) for an emergent cesarean birth.


  • Verify fetal heart rate in the OR.


  • Intrauterine fetal resuscitation measures may include oxygen delivered at 10 L by face mask and increased (or initiation of) intravenous fluid administration, but these measures should not delay transport of the woman to the operating room.


  • Educate and support the mother and family about the emergency and interventions.


  • Document events, interventions, and responses as soon as possible.






FIGURE 16.4 A. Sims position in Trendelenburg. B. Knee–chest position.

NOTE: Perinatal mortality rates with UCP have decreased to less than 10% due to the availability of operative and anesthesia teams as well as improved neonatal resuscitation techniques.1,2


Shoulder Dystocia

Management of shoulder dystocia in the absence of a primary care provider is discussed in Module 9. This module focuses on the responsibilities of the nurse when the birth attendant is present.

NOTE: Shoulder dystocia occurs when the fetal head is delivered, but the anterior shoulder is impacted or “stuck” on the pubic arch. Shoulder dystocia complicates up to 3% of vaginal births.4


Shoulder dystocia cannot be reliably predicted or prevented. In addition, there are no reliable risk identifiers or tools that have been proven effective to prevent most cases of newborn brachial plexus palsy, a condition associated with shoulder dystocia.4 However, there are three clinical scenarios in which a provider may consider a varied birth plan4:



  • Suspected fetal macrosomia defined as an estimated fetal weight of 5,000 g in a nondiabetic woman or 4,500 g in a woman with diabetes


  • Prior shoulder dystocia


  • Mid pelvic operative birth with an estimated fetal weight of 4,000 g

If one of these conditions exists and vaginal birth is anticipated, be prepared to act rapidly to reposition the woman and provide suprapubic pressure. Also, have an extra nurse at delivery, Anesthesiology to management maternal pain needs, and the newborn resuscitation team in case the baby is depressed at birth. Associated maternal and newborn risks of shoulder dystocia include the following.

Risks to the Mother



  • Postpartum hemorrhage


  • Third- or fourth-degree episiotomy and/or laceration

Risks to the Baby



  • Brachial plexus injury


  • Fracture of clavicle and/or humerus


  • Cerebral hypoxia


  • Death

A team approach and effective, calm communication during shoulder dystocia is essential. All staff should be prepared to respond emergently should a shoulder dystocia occur.


Primary nursing measures to relieve shoulder dystocia includes maternal positioning (McRoberts and Gaskin maneuvers) and suprapubic pressure. These maneuvers are considered to have the lowest risk with the highest rate of effectiveness. The McRoberts maneuver is accomplished by positioning the woman’s legs back with the thighs on her abdomen. This straightens the sacrum and decreases the angle of incline of the symphysis pubis, making it easier to deliver the anterior shoulder (Fig. 16.5A to C). An alternative position is the “all fours” Gaskin maneuver, which has
a high success rate; however, it may be difficult to accomplish if the woman has a dense regional block.5 The provider may also ask for suprapubic pressure over the anterior fetal shoulder. Downward and lateral pressure is applied in an attempt to dislodge the shoulder (Fig. 16.6). Lowering the bed and side rails may be helpful to accomplish these measures, but precautions should be taken to protect the mother and allow the delivering provider optimal alignment for additional maneuvers. A step stool may also be used to assist with elevation for suprapubic pressure.






FIGURE 16.5 A. McRoberts maneuver position. B. Normal position of the symphysis pubis and the sacrum. C. The symphysis pubis rotates and the sacrum flattens.






FIGURE 16.6 Suprapubic pressure.

NOTE: A combination of the McRoberts maneuver and suprapubic pressure may relieve more than 50% of shoulder dystocia cases.4

The provider determines the need and sequencing of additional measures if the shoulder dystocia is not relieved. These include the Rubin maneuver, delivery of the posterior arm (Jacquemier maneuver), Wood’s screw maneuver, cephalic replacement (Zavanelli maneuver), symphysiotomy, and/or deliberate fracture of the clavicle.

NOTE: ACOG recommends antepartum screening for risk factors for shoulder dystocia and consideration of elective cesarean birth if the estimated fetal weight is above 5,000 g (4,500 g for diabetic women).4


Accurate documentation of the event is essential. Nursing documentation of the event should include the following:



  • Specifics about nursing maneuvers performed, the order in which they were performed, who directed the maneuvers, and attempts to assess fetal status during the event


  • Duration of the event (specifically the time from delivery of the fetal head to the delivery of the body)


  • Team members involved and their role


  • The anterior shoulder that was impacted (right or left)


  • Fetal assessment prior to birth


  • Umbilical cord gases


  • Resuscitation measures for the newborn (newborn team documents care provided)


  • Newborn assessment


Be prepared to thoroughly assess the newborn at birth for signs of injury. (See Module 18 for additional information regarding newborn assessment.) Members of the team involved in the event should also take time to speak with the woman and family after the event to educate, explain, and support.



Amniotic Fluid Embolism


Amniotic Fluid Embolism (AFE) is a rare event with an estimated incidence of 1 in 40,000 deliveries.6 Many aspects of AFE remain unknown, including risk factors for this devastating syndrome. Despite the name amniotic fluid embolus, this syndrome is not the result of amniotic fluid entrance into maternal circulation or embolism. Maternal pathophysiology is more likely related to an aggressive immunologic response to fetal tissue and massive release of endogenous and/or inflammatory mediators causing:



  • Sudden maternal hypoxia


  • Cardiovascular collapse


  • Coagulopathy7

It has also been proposed that intrauterine infection may also be a signaling factor in the release of endogenous mediators resulting in a clinical picture similar to anaphylaxis or septic shock.7

NOTE: The maternal mortality rate with a diagnosis of AFE is between 20% and 60%, with only 15% of patients surviving neurologically intact in a national registry.6


The symptoms associated with AFE are listed in Table 16.1. These symptoms have an acute onset and lead to rapid maternal and fetal compromise.








TABLE 16.1 SYMPTOMS OF AFE AND RATE OF OCCURRENCE












SYMPTOMS OCCURRING FREQUENTLY (IN 80–100% OF CASES) SYMPTOMS OCCURRING WITH MODERATE FREQUENCY (IN 20–80% OF CASES) SYMPTOMS OCCURRING INFREQUENTLY (IN LESS THAN 20% OF CASES)
Hypotension
Fetal compromise
Pulmonary edema or acute respiratory distress syndrome
Cardiopulmonary arrest
Cyanosis
Coagulopathy
Dyspnea
Seizure, tonic–clonic
Atony
Bronchospasm
Transient hypertension
Cough
Headache
Chest pain
From Clark, S. L. (2014). Amniotic fluid embolism. Obstetrics & Gynecology, 123(2), 337–348; Romero, R., Kadar, N., Vaisbuch, E., et al. (2010). Maternal death following cardiopulmonary collapse after delivery: Amniotic fluid embolism or septic shock due to intrauterine infection? American Journal of Reproductive Immunology, 64, 113–125.


In the national registry data, 70% of the women diagnosed with AFE were in labor, 19% of cases occurred during cesarean delivery, and 11% of cases occurred during the early postpartum period. AFE has also been reported to occur during amnioinfusion, termination of pregnancy, and abdominal trauma.


Nursing care for the woman experiencing a possible AFE is focused on supportive therapy.



  • Immediately call a rapid response or code as determined by the patient’s status.


  • Immediately notify the obstetric provider, anesthesia, and neonatal resuscitation staff (if patient is undelivered) and obtain a crash cart.


  • Continuously monitor the fetus if the woman is undelivered and anticipate an emergency cesarean birth and neonatal resuscitation.


  • Administer high-concentration oxygen by face mask to maintain normal saturation. Anticipate and prepare for intubation and ventilation.


  • Initiate cardiopulmonary resuscitation (CPR) if the woman experiences cardiac arrest. If the mother does not respond to CPR, prepare for a perimortem cesarean section within
    4 minutes following the maternal arrest since maternal and neonatal outcomes are linked to the time interval between maternal cardiopulmonary collapse and birth.


  • Initiate peripheral intravenous access with a large-bore cannula. Anticipate central line placement and/or multiple peripheral lines.


  • Treat hypotension with positioning and crystalloid boluses. Anticipate the need for massive blood product replacement, vasopressors, and inotropic agents.


  • Anticipate arterial line placement for continuous blood pressure monitoring and access for blood gases and laboratory specimens.


  • Prepare the woman and family for transfer to an intensive care environment or tertiary care center after initial stabilization.


Obstetric Hemorrhage

The following intrapartum emergencies are grouped together because they are all associated with complications from blood loss. Obstetric hemorrhage is the leading cause of maternal mortality worldwide, with one death occurring every 4 minutes. In the United States, the incidence of obstetric hemorrhage is 2.9% of all births and hemorrhage requiring blood transfusion has increased 114%.8 Hemorrhage is responsible for approximately half of severe maternal morbidity such as acute respiratory distress syndrome (ARDS), acute kidney injury, and disseminated intravascular coagulation (DIC).9 Although the maternal physiologic adaptations to pregnancy (Display 16.1) allows for compensation of blood loss at birth, if bleeding is excessive, previously effective compensatory mechanisms to maintain cardiac output (systemic vasoconstriction, tachycardia, and increased myocardial contractility) begin to fail and symptoms of shock and impaired organ perfusion become evident. Situational awareness and early recognition of maternal compromise is necessary to prevent maternal morbidity and mortality.


Data have demonstrated that 54% to 93% of maternal deaths related to hemorrhage are preventable due to an under appreciation of blood loss and failure to provide adequate volume replacement in a timely manner.8,9,10 Development and implementation of comprehensive, evidence-based hemorrhage protocols have been shown to improve recognition and management and decrease maternal blood transfusions and peripartum hysterectomy.11 Therefore, The National Partnership for Maternal Safety recommends all the following10:



  • U. S. Birthing Facilities have an obstetric hemorrhage protocol


  • Hemorrhage kit or cart that contains appropriate medications and supplies


  • Partnership with a local blood bank for blood products


  • Active management of the third stage of labor

Assessing, recording, and reporting estimated blood loss (EBL) is one intervention in an obstetric hemorrhage protocol. Visual estimation can be extremely difficult to determine and may be underestimated by 30% to 50%.12 Underestimation is especially prevalent in cases of hemorrhage and cesarean sections when there is mixing of blood with amniotic fluid and irrigation solutions. To improve accuracy and situational awareness, quantified blood loss (QBL) measurement is recommended with each birth or if obstetric hemorrhage occurs during the antepartum or postpartum periods. QBL is an objective tool that improves recognition and management of hemorrhage and may lead to a decrease in transfusions, surgical intervention, and length of stay.13 QBL can be accomplished by weighing items soiled with blood, subtracting the dry weight of those items, and converting each gram to milliliter. Graduated under buttocks and operative drapes also assist with measurement.13

HELPFUL HINT: Having a chart with the dry weights of commonly used linens and pads will assist in determining the QBL.


NOTE: By the time a pregnant or postpartum woman exhibits signs of compromise such as dizziness, hypotension, and oliguria, the amount of blood loss is significant!

General nursing considerations for obstetric hemorrhage are as follows:



  • Call a Rapid Response as indicated by maternal status and availability of team members.


  • Place a Foley catheter and monitor intake and output every hour until stable. If urine output falls below 30 mL/hr, assess the woman for other signs and symptoms of volume depletion (tachycardia, tachypnea, weak peripheral pulses, dry mucus membranes).


  • Quantitative, cumulative blood loss totals are helpful to anticipate maternal decompensation prior to laboratory analysis.


  • Obtain intravenous access; multiple large-bore intravenous catheters or central line placement is necessary for class III or IV hemorrhage. Note: some hospitals use classes of hemorrhage to relate the amount of blood lost to maternal signs and symptoms. These classes are outlined in Table 16.2.








TABLE 16.2 CLASSIFICATION OF HEMORRHAGE
























CLASS BLOOD LOSS PATIENT SYMPTOMS
I 1,000 mL
(15%)
Dizziness
Palpitations
Minimal blood pressure changes
II 1,500 mL
(20–25%)
Tachycardia
Tachypnea
Weakness
Narrowing pulse pressure ≤30 mm Hg
Delayed capillary refill after blanching palm at base of fingers at ulnar margin
Orthostatic hypotension
III 2,000 mL
(30–35%)
Hypotension
Marked tachycardia (120–160 beats/minute)
Tachypnea (30–50 breaths/minute)
Skin—cold, clammy, pale
Restlessness
IV ≥2,500 mL blood loss
(40%)
Symptoms of profound cardiogenic shock
BP may be absent
Peripheral pulses may be difficult to palpate
Air hunger
Oliguria or anuria
From Francois, K. E., & Foley, M. R. (2012). Antepartum and postpartum hemorrhage. In Gabbe, S. G., Simpson, J. L., & Niebyl, J. R. (Eds.), Obstetrics: Normal and problem pregnancies (6th ed., pp. 415–444). New York: Churchill Livingstone.

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Nov 6, 2018 | Posted by in GYNECOLOGY | Comments Off on Obstetric Emergencies
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