Pathway 5: Obstetrical Emergencies
The team continues the resuscitation along the pathway suggested by the initial clinical impression. Each pathway includes a complete, thorough, and rapid physical examination with additional history taking. The team leader is wary of conditions that may not be apparent. To obtain additional clinical data or to correct a missed or newly developed condition, the team leader repeats the initial survey if the patient is not responding satisfactorily.
Obstetrics patients pose unique problems in emergency situations. Both maternal and fetal conditions must be systematically evaluated and treated. The questions in this pathway address a variety of obstetrical problems. Use the preceding table to cross-reference information in this pathway with the diagnostic and treatment portals.
It is important to determine the gestational age of the pregnancy. Determine the date of the patient’s last menstrual period and whether a pregnancy test has been done. When did the patient feel the first movements of the fetus (quickening)? Measure the fundal height to determine the uterine size.
Listen for fetal heart tones (FHTs). If FHTs are not present, use ultrasound to detect cardiac activity. In early first trimester pregnancies, cardiac activity or even a gestational sac on ultrasound may not be apparent. Correlation of ultrasound findings with a quantitative HCG may be helpful.
Physiology of Pregnancy (Vol III—OB1 PHYSIOLOGY OF PREGNANCY)
Several physiological changes occur during pregnancy. These changes may be used diagnostically. For example if the uterus is at the level of the umbilicus, the gestational age is about 20 weeks or (5 months).
Other physiological changes are important during assessment of other conditions such as shock due to trauma. For example, if the patient has a low blood pressure, this may be due the supine hypotensive syndrome caused by the weight of the uterus pressing on the vena cava when the patient is lying on her back. Placing the patient on her left side should relieve this.
Ultrasound (Vol III—OB2 ULTRASOUND USE PORTAL)
Ultrasound
may be helpful in addressing a number of important clinical questions
that arise during labor and delivery such as gestational age, cardiac activity,
multiple gestation, and fetal presentation. Ultrasound can also be
useful in assisting with common procedures such as amniocentesis.
Bleeding in Early Pregnancy/Miscarriage (Vol III—OB3 BLEEDING IN EARLY PREGNANCY/MISCARRIAGE)
Vaginal bleeding in the first trimester occurs in 30% to 40% of all pregnancies. Approximately half of this percentage of women miscarry at a gestational age of 12 weeks or fewer.
Obstetrical causes of bleeding include spontaneous abortion, normal pregnancy, embryonic death, blighted ovum, ectopic pregnancy, and trophoblastic disease. Non-obstetrical causes include vaginitis, cervical polyps, cervical erosion, cervicitis, or cervical cancer. Non-uterine causes of bleeding should be apparent during the speculum exam.
Laboratory tests for the stable patient without other medical problems should include a hemoglobin, quantitative beta HCG, and Rh status. In a clinically stable patient, either watchful waiting or surgical intervention is medically reasonable.
Dilatation and Curettage (Vol III—OB4 DILATATION AND CURETTAGE)
f the patient is bleeding heavily or retaining tissue, the patient is considered unstable and may need a dilatation and curettage.
If peritoneal signs are present, a laparoscopy is indicated: laparotomy may be indicated if the patient is unstable. As an alternative, if laparoscopy is not available, culdocentesis may be performed.
FHT Monitoring (Vol III—OB5 FETAL HEART TONE MONITORING)
Intrapartum electronic fetal monitoring is a useful tool in the emergency setting where intervention may result in a live infant (23 to 24 weeks minimum). Fetal heart rate changes are repetitious changes termed accelerations or decelerations. Determine if the FHTs are reassuring, warning, or ominous, and note the relationship to contractions. Review the tracing in a systematic fashion.
Preterm Labor Management (Vol III—OB6 PRETERM LABOR MANAGEMENT)
Palpate the uterus for strength, duration, and frequency of contractions. If gestational age is < 36 to 37 weeks, treat for preterm labor. (Approximately 9% of all neonates in the United States are born prior to 37 completed weeks of gestation.)
Bleeding After First Trimester (Vol III—OB7 BLEEDING IN THE SECOND HALF OF PREGNANCY)
Causes of bleeding range from normal to life-threatening and must be evaluated systematically. Ultrasound evaluation is needed. Examine the patient and consider the possibility of bloody show (blood-stained mucus), placental abruption, placenta previa, and vasa previa.
Hypertension in Pregnancy (Vol III—OB8 HYPERTENSION IN PREGNANCY)
Hypertension in pregnancy can be differentiated into 3 categories: chronic or essential hypertension, pregnancy-induced hypertension (PIH), and preeclampsia/eclampsia. PIH is present if the BP is > 140/90 or if there is a systolic rise of 30 mm Hg or diastolic rise of 15 mm Hg during pregnancy.
Preeclampsia is PIH with facial/hand edema and proteinuria > 1+ on urine dipstick (> 300 mg proteinuria/24 hours) between 20 weeks gestational age and 1 week postpartum. Eclampsia is preeclampsia with either coma or seizure present.
Trauma in Pregnancy (Vol III—OB9 TRAUMA IN PREGNANCY)
The team leader must be aware of the physiology of pregnancy (including consideration of the mother and child as two separate patients). Treat serious maternal or fetal trauma with the same systematic approach as other kinds of trauma. Most maternal deaths are due to head injury and hemorrhagic shock. Most fetal deaths are unexplained or are due to maternal death or placental abruption; however, if maternal abdominal trauma is involved, abruption is the most common cause.
Emergent Cesarean (Vol III—OB10 EMERGENCY CESAREAN SECTION)
The physician may need to perform an emergency cesarean section to save the baby when the mother is near death or has just died. Perform the cesarean section in the ED, unless an operating room is immediately available.
Imminent Delivery (Vol III—OB11 IMMINENT DELIVERY)
Determine if delivery is imminent. If the patient is crowning or the perineum is bulging, prepare for immediate delivery. The team should be prepared to do this in the ED or other locations as indicated. Have emergency kits available for quick retrieval.
Move the patient quickly to an area where delivery can occur in a controlled manner and the infant can be resuscitated if necessary. (Vol III—NRP2 DRUGS IN NEONATAL RESUSCITATION, NRP3 MECONIUM SUCTIONING)
If the cord is palpable on vaginal bimanual exam, a cord prolapse is present. Pulsation in the cord is typically palpable if the fetus is viable. Immediately place the patient in the knee-chest position; then, with your hand in the vagina, push the presenting part up as high as possible and hold the head in that position until accomplishing delivery by cesarean section.
Malpresentation/Malposition (Vol III—OB12 MALPRESENTATIONS AND MALPOSITIONS)
Breech presentations are most common in preterm fetuses. Other factors that predispose to breech presentation include multiparity and uterine relaxation, hydramnios, hydrocephaly, previous breech birth, tumors in the pelvis, multiple gestation, oligohydramnios, anencephaly, and uterine anomalies. Breech presentations are classified as frank, complete, or footling. Manage footling breeches by cesarean delivery. Frank and most complete breeches are managed on a case-by-case basis.
Assistance for Delivery (Vol III—OB13 ASSISTED DELIVERY)
Occasionally it is necessary to deliver the neonate quickly due to abnormal FHTs. Assisted deliveries may also be necessary to avoid maternal exhaustion. Regional analgesia may interfere with voluntary expulsive efforts. Forceps or vacuum delivery may be used.
Shoulder Dystocia (Vol III—OB14 SHOULDER DYSTOCIA)
Shoulder dystocia is the impaction of the anterior shoulder against the symphysis pubis after the fetal head has been delivered. Shoulder dystocia is a life-threatening emergency for the fetus and needs to be recognized and treated quickly to avoid morbidity or even mortality. Over 50% of all shoulder dystocias occur in the normal birth weight neonate and are unanticipated. Identify risk factors early to prepare for this complication.
Postpartum Complication (Vol III—OB15 THIRD-STAGE AND POSTPARTUM EMERGENCIES)
Retained placenta is the inability to deliver the placenta within 30 minutes after birth. Postpartum hemorrhage is bleeding in excess of 500 cc in the first 24 hours after completion of the third stage of labor. Do not underestimate the amount of blood loss. Postpartum hemorrhage can be caused by: (1) uterine atony, (2) birth trauma, (3) uterine inversion, (4) uterine rupture, or (5) acquired coagulopathy.
Thromboembolic Disease (Vol III—OB16 THROMBOEMBOLIC DISEASE AND PREGNANCY)
Superficial thrombophlebitis may be treated with elevation, analgesia, elastic stockings, heat, and ambulation. Deep vein thrombosis above the knee requires heparin therapy. Thrombosis below the knee is often treated conservatively with adjunctive measures. Any evidence of progression requires heparin therapy.ß