OB Emergencies
The leading cause of maternal and fetal morbidity and mortality.
What is Postpartum Hemorrhage.?
uterine atony, failure of uterus to contract, accounts for most cases of hemorrhage and is leading cause of postpartum blood transfusions and hysterectomy
Medication given in the second trimester of pregnancy to prevent Rh incompatibility in pregnant women with Rh-negative blood who are carrying a Rh-positive fetus, or given to a Rh-negative woman after a miscarriage or abortion.
What is RhoGAM?
RhoGAM given via IM injection contains a small amount of Rh-positive proteins that prevent the mother's immune system from producing antibodies against Rh positive blood. Failure to receive RhoGAM can lead to hemolytic disease of fetus and newborn during delivery and in future pregnancies.
During pregnancy the lower esophageal sphincter tone relaxes due to progesterone increasing the risk of this in up to 50% of women?
What is Pyrosis (heartburn)?
This class of pain medications should be avoided during pregnancy due to potential adverse fetal effects.
What are NSAIDS?
Prior to a D&E, this is ordered to give in Pre-Op 90 minutes prior to procedure when the patient is 11-16 weeks gestation.
What is Cytotec?
600mcg of vaginal Cytotec to soften & dilate the cervix; Laminaria placed greater than 16 weeks gestation, typically the day prior
Monitor for labor symptoms - any vaginal bleeding heavier than spotting & significant pain
Medication of choice when maternal hypotension is not responsive to repositioning and fluids?
What is phenylephrine?
Evidence shows it is safer - less detrimental effect on umbilical artery pH compared with ephedrine (reduces fetal acidosis)
Drug that could be ordered to administer preoperatively to decrease the risk of aspiration.
What is sodium bicitrate, famotidin (Pepcid), or metoclopramide (Reglan)?
Pregnant women are at an increased risk for aspiration pneumonitis. Many anesthesia providers administer preop meds to help prevent.
What is Heart Rate?
The best position for a pregnant woman to prevent aortocaval compression and improve hemodynamics and gas exchange.
What is left lateral.
(Supine can reduce uterine blood flow)
An available resource if your patient (or you) need emotional support in Pre-Op or PACU.
Who is the Chaplain?
#84063 or in Vocera under Spiritual Care Services
Also, "Perinatal Loss Coordinator" consult order can be placed who will contact the patient with more resources
Decedent Affairs - Leave a message if patient wants information on fetal disposition, burial/cremation information. It may be 1-2 days before patient hears back from Decedent Affairs
Signs of premature labor to monitor for in Pre-Op and PACU.
What are rupture of membranes, increased fetal heart rate, loss of vaginal mucous plug, uterine contractions, restlessness of mother?
A synthetic hormone that can be given by continuous IV infusion after delivery to help the uterus contract and prevent excessive bleeding.
What is Oxytocin (Pitocin)?
Standard concentration at UCHealth is 30 units/500 ml with rate of 3-30 units/hour. PACU RN should infuse using Alaris Pump. Dual sign off is required!
Pregnant women are at 4-5x increased risk of this coagulation complication.
What is DVT/PE/blood clot?
blood clots easier during pregnancy, accounts for 9.3% of all maternal deaths in the US
This additional OB assessment should be completed in Pre-Op for pregnant women less than 24 weeks gestation prior to surgery.
What is doppler fetal heart tones?
If less than 24 weeks, Fetal Heart Rate should be documented by doppler assessment in Pre-Op and PACU (HR typically audible 10-12 weeks gestation)
The surgical management to remove products of conception, usually after 13 weeks of pregnancy.
What is a D&E (dilation & evacuation)?
Any patient being treated in the Perioperative setting for pregnancy loss should receive support from staff.
The patients could present for any of the procedures below:
D&E (dilation & evacuation): the surgical management to remove products of conception usually after 13 weeks of pregnancy
This can be due to fetal demise (spontaneous intrauterine death) or for a therapeutic abortion (can include reasons secondary to pregnancy and/or fetal complications) to terminate a pregnancy
D&C (dilation & curettage): the surgical management to remove tissue from the uterus
Pregnancy related examples include: molar pregnancy, missed abortion/miscarriage, spontaneous abortion with retained products of conception, or therapeutic abortion to terminate a pregnancy typically prior to 13 weeks gestation
Note: Non pregnancy related examples include: uterine bleeding, polyps, cancer, retained placenta postpartum (had the baby & has retained placenta)- DO NOT treat these patients as if they are here for pregnancy loss
It is IMPERATIVE you understand if the procedure is pregnancy related or not- if in question, read the H&P and/or post-op note- the surgeons will clarify the reason for the surgery
Ectopic pregnancy: a pregnancy located outside of the uterus, most often found in the fallopian tube
If not removed the patient is at large risk for a rupture and hemorrhage which is an emergent condition.
What is Uterine Artery Embolization (UAE)?
UAE is a minimally invasive procedure done in IR, and is an effective treatment for PPH with clinical success rate of 86-96%.
Medication given to help prevent seizures in pregnant women with preeclampsia, and to delay preterm birth for neuroprotection and lung development.
What is Magnesium Sulfate?
20 gram/500ml infusion - 4-6 grams bolus over 20 minutes. Maintenance 1-2 grams/hour continuous infusion. Monitor sedation, deep tendon reflexes. and lung sounds hourly. Pt typically on bedrest. Check for labs, serum mag typically ordered q6hr.
Total blood volume increases 45% while RBCs increase by 30% in pregnant women leading to this common condition.
What is physiologic anemia? (dilutional anemia)
blood volume increases more than RBCs which leads to physiologic anemia (% of hgb decreases, making it harder to carry oxygen); Iron rich food or supplements important! Hgb 10-11 g/dL typically (normal levels 12-15 in healthy, non-pregnant women)
Continuous fetal heart rate monitoring and uterine monitoring is recommended for all pregnant patients undergoing non-obstetric surgery if the fetus is greater than this gestational age?
What is 24 weeks?
Continuous monitoring in OR if possible, and in PACU post procedure. - Operational Workflow: Obstetrics: Fetal Monitoring During a Non-Obstetric Surgery or Procedure
Name of the Care Note/Krames Note to add to the patient's discharge instructions (AVS).
What is "Coping with Pregnancy Loss" Note.
Any patient presenting to the perioperative department to manage their pregnancy loss should receive the "Coping with Pregnancy Loss" CareNote
Even patients that "chose/elected" to have the procedure, or "seemed fine" should receive this CareNote with their discharge instructions
Please DO NOT feel you need to read the entire CareNote to the patient upon discharge. A simple sentence might include "I've attached some supportive resources to your discharge instructions for you to refer back to if you feel like you need any contact information or more support once you are home."
If patient changes their mind and wants a private burial/cremation, contact Decedent Affairs and leave patients name, MRN and date of procedure and they will contact patient
A serious pregnancy condition where the placenta grows too deeply into or through the uterine wall that can lead to premature labor, hemorrhage, and a hysterectomy.
What is Placenta Accreta?
Increased risk w/ multiple pregnancies and prior c-section or uterine surgery and in women older than 35 yo.
The 4 medications you will get when you select the "OB Hemorrhage" Kit in the Pyxis.
What are Cytotec (Misoprostol), Carboprost (Hemabate), Methergine (Methylergonovine), and Oxytocin (Pitocin)?
NOTE: The OB unit also has TXA in their OB hemorrhage kit.
Pregnant women undergoing general anesthesia often require a 30-40% decrease in this anesthetic.
What are volatile gasses/inhaled gasses?
Potency of inhaled gasses is greater in pregnant women so often require 30-40% decrease; faster induction and greater risk of hypoxemia, pre-oxygenation very important!
Normal fetal heart tones.
What is 110-160? (Normal fetal heart tones)
<110 Bradycardia (causes: decrease in uterine placental blood flow, maternal hypotension, maternal medications, severe hypoxia)
>160 Tachycardia (infection, maternal fever, dehydration, anxiety, mild hypoxia)
Example of something you can say to offer a supportive presence to your patient.
What is "I'm sorry you have to be here for this today" or "I'm sorry you have to go through this"
Simple acknowledgment to show supportive presence. Ask if there is anything we can do to make them more comfortable (warm blanket or heat pack, support person to bedside, pain management, etc.)