SM
MRN: ###
Location: CCU 8
History : 36 P1001 37+ weeks,, EDD 8/12/14 with severe pulmonary hypertension
OB History : SVD x1 , 2002
Fetus: Symmetric IUGR (EFW 4%, normal fluid, normal UA Dopplers, normal
posterior placenta)
Language: Triginyan – Interpreter David Solomon via JHH International Services
Chest CT: no PE. Diffuse ground glass opacities, no fibrosis, no evidence of
emphysema
RH Hemodyanmics:
CO 4.2; PA systolic pressure 106 mm Hg
Scheduled Delivery Date: 7/31/14, Cardiac ORs
TEAMS
OBSTETRIC
PRIMARY CONTACT
Maureen Grundy - fellow
Edie Gurewitsh – attending
Robert Ehsanipoor- attending
Sonia Dutta – chief resident
NUMBER
55850 (L+D)
410-220-7558 ( Grundy cell)
43066 ( MFM on call attending
phone)
OB ANESTHESIA
Jamie Murphy – attending
Maggie Lesley - attending
Todd Kolb – attending
Bryan Maxwell - attending
CT Surgery fellow on service
55850 (L+D)
David Thiemann - attending
Fellow on call
PING
55255
PULMONARY CRITICAL CARE
CARDIAC ANESTHESIA
CT SURGERY – to mobilize
ECMO
CCU attending (through 8/1)
NICU
PING
PING
31109
If urgent need for delivery , call these people
-
OB attending 55850, 43066
OB anesthesia 55850
Cardiac anesthesia on call – PING or through CCU
Todd Kolb MD (Pulm critical care) – PING
David Thiemann (CCU attending through 8/1) – PING
CT surgery fellow for possible ECMO activitation - 31109
-
SURGICAL PREP
NPO p MN day of surgery
Heparin gtt OFF if signs of labor, fetal nonreassurance, or 8 hours
prior to surgery
Dorsal supine position to facilitate possible need for femoral line
Operative prep: From neck to groin for possible ECMO – if
peripheral cannulation not possible  central cannulation with
median sternotomy – REQUIRES WHOLE BODY PREP
POTENTIAL DELIVERY SCENARIOS
SCENARIO 1
SCHEDULED C-SECTION
-
July 31st, CCU OR scheduled from 845 to
12 pm
Anesthesia: OB and cardiac, plan for
epidural
Preop: NPO p MN, Heparin gtt OFF 8 hr
prior to surgery
Alert NICU morning of procedure
Patient will be s/p 1 week of Flolan
Intraop: supine positioning to allow for
femoral access in case of ECMO, whole
body prep
SCENARIO 2
MATERNAL CARDIAC EMERGENCY
-
Contact OB (55850), NICU (55255), and
OB anesthesia immediately
If acute decompensation prevents
getting to OR, c-section supplies are at
the bedside in CCU
In setting of code, c-section would be
performed emergently at bedside
If time safely permits and continues to
have maternal indications for c-section ,
can also try to proceed to cardiac ORs to
proceed with delivery
SCENARIO 4
FETAL DECOMPENSATION
SCENARIO 3
LABOR OR RUPTURE OF MEMBRANES
-
-
-
Call OB team immediately at 55850 if
patient demonstrates any signs of
contractions, vaginal bleeding or leaking
fluid
Patient has been instructed with help of
interpreter to alert staff to such
complaints
If labor, will need to mobilize all teams to
proceed immediately to CCU OR for
delivery
Turn off Heparin GTT
If labor is rapid and evaluation
determines that vaginal delivery is
imminent, forceps and vacuum are
available at bedside for operative vaginal
delivery with passive second stage
Intraop: same as above
-
if a prolonged fetal bradycardia, delivery
plan will need to be quickly mobilized
Call OB, anesthesia, and NICU teams
immediately
Would avoid terbutaline in this setting
which would likely cause significant
maternal tachycardia
If maternal status allows, would ideally
prefer to move to cardiac ORs
If maternal decompensation
simultaneously, would likely determine
need for emergent c-section at bedside
Intraop: same as above if permits