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JUST THE TWO OF US… The High Risk Obstetrical Patient

Objectives

• Discuss expected maternal physiological changes

• Review gestational facets

• Disclose emergent maternal / fetal complications

• Discuss emergent treatment modalities for each

complication

Maternal Physiological Changes

• HR increases 15 – 20 BPM

• BP decreases in 2nd

trimester by 5 – 15 mmHg

• BP increases in 3rd trimester

by 10 mmHg

• Cardiac output increases by

3rd trimester 35 – 50 %

• Dilutional anemia

• Plasma increases by 40% – Increased clotting factors

– Increased risk of PE

• Heart is elevated and rotated

• Progesterone relaxes

sphincters

• Decreased

functional/residual lung

volume

• Mild tachypnea and

respiratory alkalosis

• Delaying gastric emptying

• Risk for fall injuries/off-

balance

Maternal Age

Patients’ less than 16 years or greater

than 35 years of age will have

increased incidences of

complications.

German female delivered at age 64

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Preterm: Prior to 38 weeks GA

Full Term: 38 – 42 weeks GA

Post Term: After 42 weeks GA

#1 Cause of Preterm Labor

Infection

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Obtaining History and Assessment

• LMP/EDC

• Gestation

• TPAL

• Gravidity

• Parity

• AMPLE to include surgical

history/previous C-section

• Prenatal care

• Chief complaint/general

impression

• Contractions = OPQRST,

duration, frequency

• Status of membranes

• Fundal height

• FHT’s and fetal movement

• Vaginal inspection

• H/O trauma

Stages of Labor

• First stage – onset of contraction to full

dilation of the cervix

• Second stage – full dilation of the cervix to

delivery of the neonate

• Third stage – delivery of the neonate to

delivery of the placenta

Fact!

The second stage of labor ends with delivery

of the infant

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Pre-Term Labor (PTL)

• Regular uterine contractions prior to 38 weeks gestation

• Sufficient frequency and intensity to cause progressive effacement and dilation of the

cervix

• Look for S/S of imminent delivery, determine status of amniotic membranes and

cervical status, assess for infection and monitor fetal heart tones/movement

• Maintain in left lateral recumbent position

• Fluid bolus

• Magnesium sulfate bolus and drip

• Terbutaline

• Steroids (Indomethacin, Celestone, Ketolorac (Toradol)

• Antibiotics for group B strep

Fetal Monitoring

Top waveform represents fetal heart rate with a baseline

FHT of 120 - 160 and bottom waveform signifies

maternal contractions

Variability is the single most important predictor of

fetal well-being

Variability

The single most important factor in predicting

fetal well-being and indicates an adequately

oxygenated autonomic nervous system in the

fetus

Accelerations

Accelerations above the baseline are associated with fetal movement but may occur with

during contractions.

The fetus exhibiting variable accelerations is likely due to a normal neurological function.

Decreased fetal movement is indicative of hypoxia

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Variable decelerations

Associated with cord compression or nuchal cord.

It can occur anytime during a contraction and is frequently V-Shaped or W-shaped in appearance.

Late Decelerations

Late decels are associated with uteroplacental

insufficiency causing the fetus to experience a

hypoxic bradycardia

Commonly associated with: PIH, DM, Smoker,

Late deliveries, and Pre Eclampsia

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Sinusoidal

Pattern

OMINOUS SIGN! FETAL DISTRESS

Accidental Tap of

Umbilical Cord

Abruptio Placenta

Ectopic Pregnancy

• LMP 6 – 8 weeks

• Lower quadrant pain with referred shoulder

pain (Kehr’s sign)

• Treat for shock and do not delay rapid

transport

• Definitive treatment is surgery and cross-

matched blood

• Rhogam if Rh –

Three factors that can determine and

confirm spontaneous rupture of membranes

(SROM) are:

– positive pooling in the vaginal vault

– positive Nitrazine (blue) and

– positive ferning under microscrope will look very

similar to a Boston fern in appearance.

• False-positive readings from the Nitrazine test

can occur with blood, cervical mucus and

povidone-iodine/betadine because they are

alkaline in nature

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Pre-Eclampsia

• The fetus on a pre-eclamptic mother during labor will commonly

experience LATE DECELERATIONS

• Triad of S/S: PIH, proteinuria and edema (especially to the face)

• May present with headache, visual disturbances (photophobia), hyperreflexia (clonus and increased DTR’s), vomiting and epigastric pain

• Treatment: Magnesium Sulfate bolus and drip

• Consider: Labetalol, Hydralazine

Eclampsia

• PIH, proteinuria, edema and seizures

• Treatment: Valium and Magnesium Sulfate

bolus and drip

• Consider: Labetalol, Hydralazine

Hemolysis, Elevated Liver Enymes and Low

Platelets

(HELLP)

• RUQ pain, jaundice, weight gain, hematuria

and malaise

• HELLP is a complication of pre-eclampsia/eclampsia

• Treat the same as for eclampsia

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Maternal Hemorrage

Uterine rupture

Fetal parts may extend through the rupture

into the peritoneal cavity –

Acute abdominal pain then no pain, absent

fetal heart tones, serial fundal height

measurements, treat for shock, Oxytocin 20 –

40 units may reduce bleeding

Placenta Previa

Bright red bleeding which the mother may

present with or without contractions – NO

VAGINAL EXAM, assess fundal height,

consider tocolytics and watch for DIC

Placenta Abruptio

Dark red bleeding with severe abdominal pain

that does not stop in-between contractions –

NO VAGINAL EXAM, assess for fetal

movement/FHT’s, assess for fundal height,

consider tocolytics and watch for DIC

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Post-partum Hemorrhage

• Blood loss in excess of 500 ml after delivery or can occur after 24 hours of delivery, treat for shock, perform fundal massage, consider Methergine and Oxytocin to control bleeding, if uterine atony persists,

– Bi-manual uterine compression is recommended

(the uterus is compressed between one hand placed on the mother’s abdomen with the other hand clenched as a

fist in the vagina with pressure maintained for approximately 2 – 5 minutes)

Fundal Massage

The primary method of controlling postpartum

hemorrhage following delivery is vigorous

fundal massage

Umbilical Cord Prolapse

• Trendelenburg or knee/chest position

• Elevate presenting part off the cord with a hand in the vagina to relieve cord compression

• If contracting, tocolytics to reduce pressure on the cord during contractions

• Can result in variable decelerations

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Breech Presentation

• Palpate cord for fetal heart rate

• After shoulders have been delivered, rotate the baby’s trunk so that the back is anterior and apply gentle downward pressure

• Apply suprapubic pressure on the mother to facilitate delivery of the head while simultaneously applying pressure on the maxilla of the fetus as upward traction is applied (Mauriceau’s maneuver)

Mauriceau’s

Maneuver

FACT!

When delivering an infant with shoulder dystocia

(shoulders are to large for the pelvic cavity) it

is important to:

Apply gentle downward traction/pressure while

applying suprapubic pressure, and flexing

mother’s legs.

McRobert’s Manuever

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Signs and Symptoms of

Imminent Delivery

• Contractions < every 10 minutes

• Increasing intensity of contractions

• Urge to push

• Vaginal bleeding

• Crowning

Indications for Emergency C-Section

• Multiple decelerations with poor variability and

rate

• Sustained bradycardia (<120 BPM for > 10 mins)

• Sinusoidal waveform

Meconium Delivery

• Suction mouth, nose and posterior pharynx

after delivery of the head, but before delivery of the shoulders

• If baby is vigorous, continue with supportive care

• If baby is NOT VIGOROUS, suction mouth and trachea

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“VIGOROUS”

• Is defined as

– Strong respiratory efforts

– Good muscle tone

– Heart rate > 100 BPM

– APGARS of 7- 10

Trauma in Pregnancy

• Placenta abruption after BENIGN collision can occur

• Transport in full spinal precautions with board slightly tilted to the left

• Up to 30 – 35 % of the maternal blood volume may be lost before S/S of

shock appear

• Maintain a high index of suspicion, MOI and seat belt use

• Assess fundal height, fetal viability/fetal movement and fetal heart tones

• Treat like any other trauma patient

Variability

The single most important factor in predicting

fetal well-being and indicates an adequately

oxygenated autonomic nervous system in the

fetus

Summary

Maintaining a sound knowledge of maternal and

fetal physiology is key to successful outcomes.

Make wise decisions…

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Questions?