OB CASE STUDY
The patient is a 19 y.o. G1, P0 at 37 weeks gestational age. She presents to L&D with
c/o uterine contractions that are frequent, painful and seem continuous. You place her on
the EFM. FHR – baseline 120’s, flat variability (less than 2 bpm), no accelerations, and
what appear to be subtle late decelerations. Her contraction pattern appears to be
continuous contractions occurring every 1-2, lasting 60-90 seconds. You palpate her
uterus and it is very hard. She appears quite uncomfortable. Temp. 98., BP 160/105,
Pulse 120, RR 20.
Allergies: Penicillin – hives. Medication: Prenatal vitamins.
You quickly scan her record:
Prenatal labs: A -, Hgb. 11. 0 at 28 weeks. Rubella immune;, HIV NR;, Hep B –NR;,
Group B strep – Positive; 1 hr GCT – 110.
Social Hx: Single. Smokes 1ppd, denies ETOH, cocaine before she was pregnant
Family Hx: Non-contributory
PMH: No surgeries. No history of major illness..
Suddenly there is a large amount of vaginal bleeding…
1. What do you suspect is the medical diagnosis?
 Placental abruption secondary to preeclampsia or cocaine use.
2. What would be your first course of action? Walk us through your decision
making, critical thinking and first initial steps.
 Notify provider of situation. The provider will come and assess the
pt. They may do a vaginal exam to see if a vaginal birth is eminent.
 Position pt on her left side, give oxygen, maintaining optimal
perfusion to the baby.
 Prepare for a cesarean birth if vaginal birth is not imminent. The
FHTs are flat and show that baby is not getting perfused
effectively and is losing the ability to compensate. Furthermore,
there are late decels which are an ominous sign.The mother’s vital
signs are also not stable and need to be assessed by the care
provider. These two things lead me to be believe that a cesarean
birth is needed. A large amount of vaginal bleeding does not give
an accurate idea of the degree of placental abruption.
 Place two large bore IVs, in preparation for surgery and the
possible need for transfusion due to hemorrhage secondary to the
poor ability of the uterus to contract after birth.
 Draw labs, ABO cross match, preeclampsia labs and OB panel.
Have matching units of blood on hand in case a transfusion is
needed.
 Insert a Foley catheter, collect urine for UA for protein and urine
tox screen.
 Take history of present illness, noting s/s of preeclampsia (RUQ
pain, blurred vision, HA, brisk reflexes, facial or generalized
edema) or recent use of cocaine.
 Give bicitra, prep abdomen (if applicable), and take to OR.
3. What is the pathophysiology of this condition?
Placental abruption is the abnormal premature separation of the placenta
from the uterine wall that can be caused by trauma, hypertension, and
coagulopathy. However, most often the cause of placental abruption is
unknown. These factors precipitate the avolution of the anchoring
placental villi from the lower uterine segment. Bleeding from this
separation fills the decidual basalis and the uterus. Women present with
bright red vaginal bleeding , abdominal or back pain, and a large and tense
uterus that does not relax between contractions, abnormal premature
contractions and fetal distress. The situation is a medical emergency as the
associated perinatal mortality rate is 12%. In cases in which the placenta is
nearly completely separated from the uterus the infant mortality rate is
100%.
4. What would you anticipate the medical orders to be?
 Stat cesarean birth
 IV bolus infusion of NS.
 Labs
 Foley Catheter
 Continuous EFM
 Oxygen
 NPO
 Rhogam
 Possibly a blood transfusion, have four units cross matched and ready.
5. What medications might be used?
 Bicitra
 Rhogam
 Possibly antibiotics for GBS positive status based on GBS sensitivity tests
(this is less of a priority if cesarean birth is ordered). If no sensitivity tests
are available, follow CDC guidelines for antibiotics to be used for GBS
for a pt with penicillin allergy.
 Magnesium sulfate postpartum (?)