Approach to Obstetrical Emergencies

General Principles:
1. Unlike medicine, in obstetrics sometimes you need to panic, and panic early.
2. Rule out that which is immediately dangerous to mother and/or fetus.
3. Call for help – if your attending is not in hospital, another OB might be. Overhead paging is ok.
4. Always get a rhythm strip
5. Just because a woman’s pregnant doesn’t mean she can’t have non-obstetric problems.

»Labor (not technically an emergency – but sometimes it feels like it…)

1. Initial action

• History – dating, prior pregnancy history, onset of contractions, fetal movement, bleeding, ROM, fevers, complications of pregnancy
• Rhythm strip (status of baby, actually in labor?)
• If question of ROM - sterile speculum exam (nitrazine, ferning, pooling)
• Vaginal exam for dilation, effacement, station (unless 3rd trimester bleeding)
• Discuss whether patient should be admitted with nurses – call attending * see call attending section in general OB info
• If position is a concern – do an U/S.
  

2. Admission

• Write an H&P (not dictated – see template)
• If patient is admitted – call PCP
• Do vaginal exams as indicated and Document
• May want to discuss pain control – find out what they’ve discussed with their PCP. The nurses are excellent at explaining and offering the hot tub, rice socks, birthing ball, etc. If your patient is expecting an epidural, it’s good to know this early.

3. Delivery

• Every attending does deliveries differently and will most likely insist that everyone does it their way. This can be frustrating, but just roll with it.
• Write a brief delivery note and dictate delivery note (see template)
• Fill in L& D summary  - found in the back of the chart
• In Augusta, complete birth certificate data form

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»Preeclampsia

Definition and Symptoms

BP> 160/110, Proteinuria > 5g/24 hour, Urine output < 500mL/24 hours, Elevated LFT’s, pulmonary edema, elevated serum creatitine, platelets<100

Visual changes, RUQ/epigastic pain, cerebral disturbances

1. Admit –

• V/S q 15-60 with DTR’s and LOC
• Bedrest and seizure precautions
• Foley to assess urine output with checks for protienuria q 1 hour
• 16-18 gauge IV with D5LR @ 50-125 cc/hr (avoid fluid overload)

2. Diagnostic Workup

• Background info – dates/LMP/US, history of HTN, BP’s though pregnancy, edema, recent wt. gain.
• Labs – start 24 hour urine collection (protein and creatinine), CBCD, CMP, uric acid, fibrinogen, Mg levels – recheck q4 hours to daily

3. Treat

• Seizure prophylaxis

Start MgSO4 4-6 grams loading dose and then 2-3 g/hour maintenance (2gm additional if seizure) * antidote calcium gluconate 1 gm IV)

• Blood pressure  

Hydralazine 2.5- 10 mg IV q 20min. or
labetolol 10-20 mg IV q10-20 minutes or
nifedipine 10-20 mg SL/PO q 20 min         
until DBP < 100 – then maintain at 100 – avoid rapid BP drops

• Deliver

Watch for pulmonary edema – treat aggressively with lasix.
Consider steroids for fetal lung maturity

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»First Trimester Bleeding

Generally pregnant women < 18 weeks will be seen in the ED and > 18 weeks seen in L&D – this is a guideline, subject to change for extenuating circumstances.

1. Initial action

• Vitals with orthostatics, ABC’s
• Hx – amount, color, pain, LMP/US/gestational dating, intercourse or trauma, contractions
• Physical Exam: speculum exam (os status, consider cervical STD and pap smear), bimanual (uterine size and adnexal tenderness), FHT

2. Diagnostic workup

• Labs – quantitative bhCG, blood type, if unknown
• If available, get Ultrasound, gestational sac should be seen by week 5 or quant > 1000.

3. Therapy

• Patient may require D&C
• Rhogam if Rh negative

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»Second/Third Trimester Bleeding

1. Initial action

• Vitals with orthostatics, ABC’s
• Hx – amount, color, pain, LMP/US/gestational dating, intercourse or trauma, contractions
• Physical Exam: abdominal exam, FHT, gentle speculum exam – NO digital vaginal exam unless placental location is known
• Consider -- O2, H/H, type and cross, 18 gauge IV, ringer’s solution wide open

2. Diagnostic workup

• CBC, type and Rh, coag, consider drug screen,
• Early decision point: abruption vs. vasa previa, vs. bloody show vs. placenta previa
  1. massive bleeding --> fluid resuscitation, type and cross,  C/S
  2. previa -->  Rhogam, consider tocolysis/steroids, expectant management, ultrasound for exact location of placenta, probable C/S
  3. abruption --> check FHT, consider amniotomy, quick delivery or possible C/S, expect neonatal resuscitation, watch for coagulopathy in mother
  4. show/labor --> routine delivery care

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»Post Partum Hemorrhage

Times to expect this – (if you’re expecting this, have a INT in place before delivery)

1. Initial assessment – Get Help!

• ABC’s, vitals
• massage uterus – consider bimanual
• give oxytocics O2
• Start 2 large IV’s – Ringers, rate dependent on level of hypotension
• type and cross for 2-4 units PRBC, H/H, coagulation studies

2. Evaluation/Treatment

• sweep for clots
• inspect birth canal – visualize cervix, if torn, call OB and clamp torn area with ring clamp
• manual uterine exploration – especially if reason to believe there is retained tissue

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»Non-reassuring Fetal Heart Tones (Fetal Stress vs. Distress)

Things to consider (not necessarily in this order):

• maternal position change
• stop pitocin
• maternal O2 (8-10L via mask)
• frequent vitals
• increase IVF – correct maternal hypotension
• change to internal monitors (fetal scalp monitor and intrauterine pressure monitor)
• if delivery not imminent – hold maternal pushing to allow FHT to recover
• terbutaline 0.25 mg SQ or slow IV push, or MgSO4 IV for hypertonic uterus
• amnioinfusion
• call for OB/Peds support --> stat C/S and/or neonatal resuscitation may be needed
• after delivery, cord pH, consider CBCD, tox sceen, placenta to pathology

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»Pre-Term Contractions/Labor

1. Initial

• Preterm labor =  20-37  weeks with regular contractions 4 in 20 minutes, documented progressive cervical change or cervical dilation >= 2cm/80%.
• dates, onset, pattern, bleeding --> if in labor, OB/gyn consult
• patient on monitor – FHT?, contractions? Palpate abdomen

2. Action

• push fluids, PO or IV – preterm contractions can be caused by dehydration
• r/o UTI
• consider a fetal fibronectin
• consider tocolytics, if delivery imminent --> peds consult.

3. Tocolysis

• absolute contraindications – placental abruption, severe bleeding with placenta previa, intrauterine infection, fetal death
• relative contraindications – cervical dilation >5cm, gestation < 20 weeks, eclampsia, pre-eclampsia, significant IUGR, DM, Pulmonary HTN

1. Brethine (terbutaline)
   0.25 mg SQ q20 minutes x 3, if effective q3-4 hours or change to 2.5 mg-5.0 mg PO q3-6 hours

2. Nifedipine
   loading dose 20 mg PO, then 1 hour later give 10 mg PO
   maintenance 10 mg PO q 3-6 hours may not exceed 80 mg in 24 hours
   hold if SBP <90

3. Magnesium sulfate
   initial dose of 4 gm IV over 20 minutes then 2gm/hour. Check Mg levels q4-6
   begin brethine ½ hour prior to stopping MgSO4. Begin nifedipine 3-4  hours after stopping MgSO4.

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