Obstetric Emergencies

Question 1

Categories of C section

Answer 1

Grade I: Emergency - Immediate threat to woman or fetus
Grade II: Urgent - maternal fetal compromise which is not immediately life threatening
Grade III: Scheduled - needing early delivery but no maternal or fetal compromise
Grave IV: Elective - time to suit woman and maternity team

Question 2

What constitutes Class I Emergency or Class II Urgent C sections?

Answer 2

NRFHR class III FHR tracings umbilical cord prolapse
Hemorrhage antepartum - placenta previa, abruptio placenta, uterine rupture, abnormal placentation, vasa previa
Hemorrhage postpartum - uterine atony, medical treatment first
Abnormal presentation
Dystocia

Question 3

presentation for cord prolapse

Answer 3

during or after rupture of membranes
mean dilation 5cm
prompt vaginal examination when FHR changes with ROM

Question 4

labor related risk factors for obstetric hemorrhage

Answer 4

induction of labor >24 hours
prolonged 2nd stage of labor
mag sulfate
laceration/hematoma
uterine inversion

Question 5

placental and uterine risk factors for obstetric hemorrhage

Answer 5

placenta previa/low lying, accrete, increta, percreta
placental abruption
retained placenta
chorioamniotis
larger uterine myoma

Question 6

four T’s for obstetric hemorrhage

Answer 6

tone
trauma (inversion)
tissue (retained tissue, invasive placenta)
thrombin

Question 7

class I hemorrhage blood loss volume and maternal response

Answer 7

900cc asymptomatic

15% blood loss

Question 8

class II hemorrhage blood loss and maternal response

Answer 8

1200-1500cc
20-25%
mild tachy, mild tachypnea, orthostatic hypotension, narrowing pulse pressure, decreased capillary refill

Question 9

class III hemorrhage blood loss volume and maternal response

Answer 9

1800-2100 cc
30-35%
severe tachy, tachypnea, cool extremities, severe hypotension, confusion

Question 10

class IV hemorrhage, blood loss volume and maternal response

Answer 10

> 2400cc 40%

oliguria, decreased LOC shock, aggressive resuscitation

Question 11

risk factors for placental abruption

Answer 11

cocaine, smoking, HTN
premature ROM, abdominal trauma, previous abruption
advanced maternal age, advanced parity

Question 12

anesthesia for abruptio placenta

Answer 12

2 large bore IVs, IVF non dextrose, blood products available
FHR monitoring
vaginal bleeding: airway exam, co morbidities, massive blood loss

Question 13

induction meds perferred for GA for abruptio placenta

Answer 13

etomidate 0.3mg/kg
ketamine 0.5-1mg/kg

but avoid ketamine with uterine hypertonus

Question 14

risk factors for placenta previa

Answer 14

previous placenta pervia, uterine surgeries including abortions, previous cs delivery

advanced maternal age, smoking hx, multiparity

male fetus

Question 15

difference between placenta previa and abruptio placenta

Answer 15

placenta previa is painless vaginal bleeding, no uterine tenderness, mild early contractions, normal uterine resting tone

Question 16

fetal M&M from placenta previa

Answer 16

increased incidence of prematurity

increased incidence of IUGR, fetal anemia, and congenital anomalies

Question 17

what to know before implementing anesthesia for placenta previa patient

Answer 17

gestational age
maternal fetal condition
amount of bleeding
type of previa

Question 18

placenta accreta, increta, percreta

Answer 18

• basal plate placenta adheres to uterine myometrium without intervening decidual layer
• placenta chorionic villi invade the myometrium
• invades through the myometrium into serosa and surrounding organs

Question 19

anesthesia for acreta/increta/percreta

Answer 19

massive hemorrhage
large bore IVs, a-line, CVP, blood products available, cell saver

GA
Sympathectomy of regional avoided
increases risk of failed airway, aspiration, etc. must be considered
advantage of intubation in face of massive hemorrhage

regional 
intubation can be avoided
awake for birth
sympathectomy disadvantage
epidural vs spinal depends on length of sx

Question 20

surgical considerations for acretra, increta, placenta

Answer 20

possible peripaprtum hysterectomy
IR consult for embolization
intrauterine balloon tamponade
consider OB suite vs main OR

Question 21

main risk factor for uterine rupture

Answer 21

uterine scars (increases with C/S or myomectomies)

others: oxytocin, prostaglandin, abdominal trauma, grand multiparity, fetopelvic disproportion, fetal malpresentation, macrosomia, instrument assisted vaginal delivery

Question 22

s/s and treatment for uterine rupture

Answer 22

s/s: nonspecific, fetal bradycardia, maternal hypotension, abdominal pain, change in uterine tone and contractions

Question 23

risk is to fetus, not mother

Answer 23

vasa previa

Question 24

neonatal volume replacement in vasa previa

Answer 24

colloid, salt and blood balanced solution

Question 25

tx for vasa previa

Answer 25

30 weeks - at hospital 36 elective C/S rupture stat delivery or CS, GA if no epidural

Question 26

causes of post partum hemorrhage

Answer 26

1. uterine atony 2. retained placental products 3. genital tract trauma 4. coagulation abnormalities 5. placenta acreta

Question 27

first ,second, and third line treatments for uterine atony

Answer 27

first line - fluids, pressors, bladder emptying, 10-20u of oxytocin IV, uterine massage second line- transfusion, removal of retained placenta, ergot alkyloids (methergine 0.2mg iM), uterine tamponade, prostaglandins, IV PGE2 or 15 methyl plostaglandin F2 alpha (IM carboprost, hemabate) third - invasive measures, embolization, surgical ligation, hysterectomy possible

Question 28

tx for uterine inversion

Answer 28

relaxation for replacement of uterus NTG 50-100 mcg or GA RSI ETT oxytocin 20u/L after replacement

Question 29

meds for hemorrhage

Answer 29

oxytocin 20-80 U/L iv - dilute!, causes hypotension methergine 0.2mg IV q2-4h- AVOID in HTN or raynaud's hemabate, carboprost - 250mg IM avoid with asthma, renal, hepatic, CV disease, risk of diarrhea ,fever and tachy cytotec- 800-1000mcg

Question 30

Iatrogenic risk factors for cord prolapse

Answer 30

Obstetric manipulation, amniotomy, artificial ROM, placement of internal monitors

Question 31

Maternal and fetal risk factors for cord prolapse

Answer 31

Maternal is multiparity Fetal - small size/weight, abnormal presentation, abnormally long umbilical cord, multiple gestation, prematurity, abnormal placental insertion, male gender, polyhydramnios, decreased FHR

Question 32

Patient history risk factors for obstetric hemorrhage

Answer 32

``` Obesity >40 BMI Multiparity, multiple gestation Fetal wt > 4000g Coagulopathy/ bleeding d/o Prior c/s uterine sx or laparaotomies Hx of OB hemorrhage ```

Question 33

S/s of abruptio placenta

Answer 33

Vaginal bleeding Abdominal pain Uterine tenderness & hypertonus Fetal distress/demise

Question 34

Fetal effects of abruptio placenta

Answer 34

Less surface area available for O2 delivery | Fetal distress demise worse than previa

Question 35

T or F If mild abruption of abruptio placenta, no evidence of NRFHR, vaginal delivery may be attempted

Answer 35

T

Question 36

Goal of placenta previa

Answer 36

Monitor and maintain pregnancy until 37 weeks | Increased bleeding calls for CS

Question 37

Treatment for uterine rupture

Answer 37

Laparotomy / CS under GA | Hysterectomy