OBSTETRICAL
EMERGENCIES
Kathleen Murray, CNM, MN, RN
Larry Whorley, BSN
Objectives
• Define and discuss nursing management for
the following emergencies:
vasa previa, abruption, rupture, amniotic
fluid embolus, DIC, and prolapsed cord.
• Discuss the nursing management of a
precipitous labor and delivery.
True Obstetric Emergencies
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Vasa Previa
Placental Abruption
Uterine Rupture
Amniotic Fluid Embolus
DIC
Prolapsed Cord
Precipitous Delivery
What should the L&D nurse do in these critical situations?
Placenta Previa
• Poor site chosen by
zygote at implantation
• Can be complete,
partial, or marginal
Vasa Previa
• Developmental disorder of the umbilical cord
• Most dangerous type of velamentous insertion
• Velamentous insertion= umbilical vessels run
from umbilical cord, between the amnion and
chorion, then into placenta
Velamentous Insertion
• Associated with earlier
placenta previa which
moved higher
• Photo is Velamentous
insertion….
Incidence
• Occurs 1 in 3000 births
• More likely in low-lying placenta (smoker,
prior C/S, preg. with multiples, assisted
conception)
• No danger to the mother
• Fetal mortality 33-100%
Etiology
• Blastocyst implants into endometrium
• Cord is central at first
• Placenta erodes at bottom edge if in lower
segment
• New growth at top edge toward fundus
• Vessels can’t migrate, are left behind
Diagnosis
• Antepartum
– Difficult to diagnosis
– Transvaginal sonography with color doppler
Signs and Symptoms
• Intrapartum
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Umbilical vessels might be felt on VE
FHR deceleration with VE
Heavy show with fetal tachycardia
Vaginal bleeding at ROM, sudden onset
of fetal distress.
Vasa Previa
• Obstetrical emergency
• Catastrophic implications for the fetus
• Fetal outcome based on quick diagnosis, an emergency
cesarean and infant resuscitation capability
Treatment
• Antepartum Diagnosis
– Scheduled Cesarean Section
• Intrapartum
– Emergency Cesarean Section
– Prepare for full infant resuscitation
Abruptio Placentae
• Definition: premature separation of the
placenta (part or all) from the uterus
• Usually after 20 weeks
Classification of Detachment
• Grade 0 – approx 250ml (<10% surface)
• Grade 1- 250-500ml blood(10-20%)
• Grade 2 – 500-1000cc (20-50%)
• Grade 3 – >1000cc (>50%)
Incidence
• Occurs in 1/120 deliveries
• 12% of stillbirths R/T abruption
• 1 in 8 recurrence rate
Etiology
• Probably necrosis and ruptured spiral arterioles in
endometrium, from:
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HTN (chronic, gestational HTN, Pre-eclampsia)
Smoking
Blunt trauma to the abdomen
Grand-multiparity
ETOH, cocaine, caffeine
Prior abruption
Uterine abnormalities, fibroids
Preterm Premature ROM
Clinical Manifestations
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80% have vaginal bleeding
Hard or rigid uterine tone
Uterine/abdominal/back pain 50%
Signs of silent bleeding – shock, oliguria
Non-reassuring FHR
Low-amp/high frequency contractions
Couvelaire uterus
Lab Findings
• Decreased H&H
• Decreased coag factors
• Presence of fetal-to-maternal bleeding
(detected by Kleihauer-Betke test)
Diagnosis and Medical
Management
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Patient history
Physical exam
Lab studies
Ultrasound
Treatment depends on severity of abruption
Exam of placenta at delivery confirms
Interventions
• Establish IV line(s) 18 gauge or larger
• Obtain labs and Type and crossmatch 2-4 units
packed red blood cells
• Rapidly administer parenteral crystalloids or colloids
• Avoid vaginal examinations
• O2 per face mask at 10 L/min
• Foley catheter
• Prepare for emergent C-Section
• Monitor Maternal V. S. / FHR, verify fetal life
• Prepare for potential DIC (happens 20% of
abruptions)
Nursing Care Plan
• Maternal stabilization
• Maintain urine output of 30-60 mL/hour
• Explain status and answer questions
straightforwardly to allay anxiety
• Position for comfort
• Anticipate grieving
Uterine Rupture
• Actual separation of the uterine
myometrium, with ROM and extrusion of
the fetus into the peritoneal cavity.
• Uterine dehiscence: a partial separation of
the old scar; membranes intact
Incidence & Etiology
• Occurs 1-8 per 1000 births (.09% to .8%)
• Uterine dehiscence occurs 2.0% of VBACs
• Related to:
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Previous uterine surgery scar
Hyperstimulation of the uterus
Trauma
Spontaneous (very rare)
Risk Factors Associated with
Uterine Rupture
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Previous uterine surgery or curettage
High dosages of oxytocin
Prostaglandins (misoprostol, dinoprostone)
Tachysystole
Grand multiparity (greater than 4)
Abdominal trauma
Midforceps rotation
External cephalic versions
Clinical Manifestations
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Sudden fetal distress
Abdominal pain
Syncope, pallor, vomiting, shock
Maternal tachycardia
Vaginal bleeding
Presenting part ascent
Medical Management
• Maternal hemodynamic stabilization
– Vital signs—observe for shock
– Note blood loss amounts (weigh chux)
– Maintain IV; order blood
• Immediate Cesarean birth
– Alert needed staff
– Move quickly to OR
• Uterine defect is repaired, or Hysterectomy
Things to Remember
• Risk of uterine rupture increases with the number
of previous incisions.
• For TOL for VBAC:
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Surgeon in-house & available throughout labor
Anesthesia in-house & available throughout labor
Prostaglandin contraindicated in VBAC patient
Avoid or minimize use of oxytocin in labor for VBAC
Stop here to play
Kathleen’s game for nurses
about Vaginal Bleeding s/s
Amniotic Fluid Embolus (AFE)
• AFE results from amniotic fluid entering maternal
venous circulation.
• Also called:anaphylactoid syndrome of pregnancy
• 3 pre-requisites:
• Ruptured membranes
• Ruptured uterine or cervical veins
• A pressure gradient from uterus to vein
• Can occur before, during or after delivery
Incidence & Etiology
• Occurs 1/8000 to 1/80,000
• AFE associated with 85% maternal / fetal
mortality. Most surviving mothers have brain
damage, and 100% develop DIC
• Common factors:
Perhaps: male infant, hx allergies
• Former list of risk factors was:
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Strong uterine contractions
Meconium in amniotic fluid
Premature placental separation
LGA, hard birth, stillborn
Older mom, multipara
Clinical Manifestations
• Acute onset of respiratory distress
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Dyspnea, cyanosis
Chest pain
Loss of consciousness, seizures
Pulmonary edema
• Acute onset of circulatory collapse
– Severe hypoxia
– Severe hypotension
• Acute onset of DIC
• Fear of death
Diagnosis & Medical
Management
• Detection of fetal squamous cells, hair,
lanugo, mucin, vernix, &/or meconium in
maternal blood and lung fields is the
cornerstone of diagnosis
• Initial Treatment:
– Cardiopulmonary resuscitation w/oxygen
– Circulatory support with blood components
Nursing Care Plan
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Ensure IV access
Initiate CPR
Give oxygen at 10 L/min
Assist with intubation
Observe for s/s of shock, coagulopathy
Help patient deal with fear of dying
Provide explanation of emergency for family
members
Disseminated Intravascular Coagulation
DEFINITION
• DIC: small blood clots develop throughout
the bloodstream
• Blocking all blood vessels
• Using up all the clotting factors
DIC: a Cascade
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Starts with stimulation of coagulant
Consumption of clotting factors
Failure of clotting at the bleeding site
Microthrombi formation throughout the
circulatory system
• Clotting factors get all used up
• Fibrinolysis and Fibrin Degradation Products
reduces the efficacy of normal clotting
DIC triggers in pregnancy
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Placental abruption
HELLP syndrome
Sepsis
Retained IUFD
Amniotic fluid embolus
Signs and Symptoms
• DIC usually develops rapidly
• Uncontrolled bleeding- cuts, IV site, mouth,
nose, vagina, skin, into urine
• Hidden intestinal, placental, abdominal,
brain bleeding
• Shock develops
Physiological Signs
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Easily bruises
IV Site bleeding
Abnormal vaginal bleeding
ROM- large blood loss
Tachycardia
Hypotension
Decreased urinary output
FHR- Tachy then Bradycardia
Testing- LAB WORK
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FDP- HIGH levels
PT-HIGH
PTT- HIGH
Bleeding times- INCREASED
Serum Fibrinogen- LOW
Platelets- LOW
H.E.L.L.P. Syndrome
TREATMENT
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IMMEDIATE DELIVERY- CRASH C/S
16 gauge IV
Oxygen
Right hip roll until delivered, etc.
Transfusion blood products
Transport to ICU
Prolapsed Cord
• Definition: umbilical cord lies beside or
below the presenting part of the fetus.
• Occurs in 0.3% to 0.6% of all pregnancies
Etiology
• Potential hazard of ROM
• Contributing factors:
– Long cord
– Malpresentation or unengaged presenting part
– Breech presentation
Diagnosis
• Variable decelerations during uterine
contractions
• Fetal bradycardia
• Cord felt or seen protruding from vagina
Medical Management
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Examiner holds baby away from cord
Reposition patient
Do not handle cord
Cover exposed cord with wet saline-gauze
Prepare for rapid delivery
– Usually crash C/S
Fetal Outcomes
• With prompt recognition & rapid delivery
fetal outcome is excellent
• Unrelieved cord compression >5min
risk of significant CNS damage and
fetal death
Precipitous Labor and Delivery
Kathleen Murray, CNM, MN
Lori Valentine, RNC
Objectives
• Define precipitous labor and
delivery
• Discuss the nursing management
of a precipitous labor and
delivery.
Definition
• Rapid labor for which the usual
preparations and attendants are not
present.
• The nurse assumes primary responsibility
for the physical and psychological safe
passage for mother and baby.
Signs and Symptoms
• May display extreme agitation
and discomfort
• Or, may be comfortable
• Increase in bloody show,
grunting , spontaneous pushing
Physiology
• Low cervical resistance with
strong contractions
• Relaxed pelvic muscles, low
resistance to fetal descent
• Multiparous, with previous
vaginal births, in vigorous labor
• Also can be caused by
oxytocin use!!
Complications
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Uterine rupture
Pelvic tissue trauma
Fetal hypoxia
Fetal head trauma
Erb’s palsy
Uterine Rupture
• Tumultuous labor with abnormally
strong uterine contractions and a firm
closed cervix
Pelvic Tissue Trauma
• 3rd or 4th degree laceration involving the
perineal body and anal sphincter
• Cervical laceration
• Urethral laceration
Fetal Hypoxia
• Vigorous labor
low fetal
oxygenation due to poor placental
perfusion
• Increased risk of meconium
• Increased risk for an acidotic newborn
requiring resuscitation
Fetal Head Trauma
• Resistance of the birth canal to
expulsion of the head, causing
intracranial trauma
Erb’s Palsy
• Injury of the brachial plexus
affecting the nerves that control
the muscles of the arm and hand
Nursing Responsibility
• Delivering baby is outside the
usual scope of practice for the
intrapartum nurse
• Responsible for the adequate
assessment of mother and fetus
• Appropriate communication with
the MD or CNM about the
patient’s status
• Documentation
Affirmative Duty Actions
• Actions the obstetric nurse is required to
perform legally include making vital
assessments, recognizing the significance
of findings, and taking actions
• Failure to act may place the nurse in legal
jeopardy (malpractice case: nurse
managed a complicated birth & the baby
died)
• Nurse held responsible for: failing to assess
the situation adequately and neglecting to
notify the MD promptly
Nursing Interventions
• Remain calm – project confidence that the
situation is under control
• Never leave the patient. Make calls from
the room for assistance.
• Continuously reassure the patient and
explain what is happening
• Encourage patient to pant when she can,
and bear down gently only when she must.
Management and Nursing Care
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Precipitous birth kit
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Need cord clamps, scissors, & bulb syringe
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Call for more nurses
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If time permits, scrub/glove/drape
Positioning
• Leave bed intact!
Relieves the nurse from worrying about
catching a slippery baby
• Side-lying position can slow descent
Delivery in Vertex Presentation
• Gentle pressure with fingers against the
fetal skull
• Don’t hold baby in!
Nuchal Cord
• Palpate for a cord. If loose, pull over head
or slip over body as shoulders deliver
• If tight, clamp x 2 and cut between clamps
• Or, Somersault manuever- deliver head, then
flex the head and torso into the mother’s
groin. The rest of the body folds and
somersaults out
Birth of body
• Assist shoulders by pressing down on the
fetal head (for anterior shoulder) and then
raising head (for posterior shoulder
followed by body)
Vertex Delivery
• Suction mouth and nose prn
• Clamp & cut cord
• Baby onto maternal abdomen. Provide
tactile stimulation/dry off with warm
towels and cover
Breech Precipitous Delivery
• Buttocks usually presents first-maintain
a hands off attitude until baby born to
level of the umbilicus
• Then pull a substantial loop of cord to
prevent tension on it during the delivery
Breech Delivery of Body
• Cover lower half of baby with a towel to
provide warmth and good control during next
maneuvers
• Birth of shoulders should be in transverse
position
• With hands placed on bony parts of hips,
gentle traction is applied downward until
axillae are visible
• Lift baby’s body carefully upward to deliver
each shoulder and arm
Breech Delivery of Head
• Baby still should face downward
• One hand under baby supporting body and
other hand over back with fingers over
shoulders on either side of neck
• Gentle downward traction until nape of neck
viewed, then lift carefully upward to allow
face to clear perineum, head gently rolls out
of the pelvis
• Flexion can be assisted by a 2nd person
applying suprapubic pressure
Care of Newborn
• Provide tactile stimulation
• Dry off baby with warm towels (if
heated-up warmer not available, stay
skin to skin with mother!)
• Assess airway, breathing and
circulation
• Assign APGAR scores
Maternal History
in Precip Birth
• If uncertain pregnancy history, assess
gestational age using the Ballard scoring
system.
• Illicit drug use?
Delivery of Placenta
• Wait and observe
• S/S of placental separation:lengthening of
cord, gush of blood, pt c/o cramping or
pressure
• Gently pull down on cord as mother bears
down
• Guard the uterus to prevent inversion of the
uterus
Delivery of Placenta
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Support placenta as it delivers to prevent
tearing/retention of amniotic membranes
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Firm massage controls bleeding
Initiate breastfeeding
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Control bleeding from lacerations by
applying ice in sterile glove, or direct
pressure with sterile gauze
References
OB Emergencies and Precip Birth
• Creasy, R, et al, Maternal-Fetal Medicine Principles & Practice, 6th
ed. 2009, Saunders Elsevier
• Cunningham, FG, et al., Williams Obstetrics 23rd ed. 2010, McGraw
Hill
• Gilbert, E, Manual of High Risk Pregnancy & Delivery, 5th ed. 2010
• Perry, S. et al, Maternal Child Nursing Care, 4th ed., 2010, Mosby
Elsevier
• International Vasa Previa Foundation, www.vasaprevia.org
• Lijoi, A, Brady, J, JAHFD, Nov 2003, Vol 16, Number 6, pp. 543-548
• Martin, EJ, Intrapartum Management Modules, 4th ed. 2010,
Lippincott
• Mattson, S, Smith, JE, Core Curriculum for Maternal-Newborn
Nursing 4th ed. 2011, AWHONN