OB meets the ED
Ann Roach, MSN, RNC-OB, RNC-MNN, ACNS-BC
Clinical Nurse Specialist
Women’s and Children’s Services
Fairview Hospital
Cleveland Clinic
http://www.babyland.my/image/cache/data/uploads/2013/03/hand-knit-baby-socks-sky-blue-bear-3-650x650.jpg
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Confidential
DOS CMEOxtober
Course 2011
2014
2010
© Cleveland Clinic 2014
My Bias
• Nursing
• OB nursing
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Everybody has a Birth Story
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Birth Story
Photo from personal files
Objectives
1. Most common diagnoses for the OB patient presenting
to the Emergency Department
2. Discuss the steps of delivering a baby in the ER
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Magic Numbers in OB
• 10 lunar months
• 280 days
• Trimesters
– 12-14 weeks
– 14-28 weeks
– 28-40 weeks
– Up to 12 weeks postpartum
•
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Go the Full
Forty
Who does this involve?
• Childbearing years
– 15-45
• Clinically
– 11-56
• Ideal
– 20-34
50% of all pregnancies are unplanned
• Optimal health prior to pregnancy
– Control your states and take your vitamins
– Stop smoking
• Antepartum issues are cared for at home
• Maternal mortality is on the rise
– Hemorrhage
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Physiologically
• Plasma volume increases 40-50% by week 30
• Hemodilution
– Red blood cells do not keep up
– Anemia
• Edema- not enough proteins in fluid
• Maternal cardiac output rises= increase in stroke volume,
increase in heart rate
– Heart displaced up and to the left
– PMI, CPR and murmurs
systemic vascular resistance falls
» BP decreases in 1st and 2nd trimesters
• Clotting factors increase—fibrinolytic activity decreases
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Respiratory
• Thoracic breathers
• Flaring of rib cage
• Hyperventilation
• Improved Oxygen delivery
– LOWERS reserve----quicker to develop hypoxia
• Compensated respiratory alkalosis
Renal
• Distended ureters
– Prone to UTI’s
– Pyleonephritis
– PTL
GI
• Slowed
– Always considered to have a full stomach
– Gastric ph is lower
– Constipation
• Gallbladder
– Acute cholecystitis can lead to the second most common
nonobstetric surgical condition of pregnancy
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Diabetogenic State
• Prolonged circulating glucose
• Additional insulin
• Gestational diabetic
• Testing done at 28 weeks
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Most General Practitioners Dislike OB
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Meet Claire
• 25 yrs old
• Single
• FOB involved—when he wants to be
• Exhaustion
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Presenting to your ER
• C/O severe abdominal pain
• Pale
• BP 100/60, P105, R20
• Guarding of abdomen
Differentials=What are you thinking?
• Flu
• Appendicitis
• PID
• UTI
• Constipation
• Pregnancy
• Kidney stones
• Stress?
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LMP 7-8 weeks ago
• Missed period
• Positive pregnancy test
• Some bleeding?
Ectopics
• Implantation outside of uterus
• 97% are in the tube
• 2% of all pregnancies
• STD’s
• Previous surgeries
• Altered hormones
• Assisted reproduction
• Maternal smoking at time of conception
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• Torn blood vessels
• Maternal death
– Abdominal pain 100% of time
– Dull and achy lower quadrant-one sided
– Colicky
– Diffuse/constant/severe
• No fever---no infection
• Medical vs. Surgical
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20 weeks
• Below 20- product of conception
• Abortion
– Spontaneous
– Induced
• Complete- pass all tissue
• Incomplete
• Inevitable
• After 20 weeks- Stillbirth--fetus
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Second Trimester Ultrasound
Photo retrieved 1/13/14 from http://medicalpicturesinfo.com/wp-content/uploads/2011/09/Omphalocele-5.jpg
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Perinatal Loss
• Grief
• Your bias
• For your patients
• Treat every pregnancy like it matters
• Gather all tissue
• Burial is allowed for any GA
4 weeks
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8 weeks
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Perinatal Loss
• I am Sorry
• D&C
• When?
• 20 weeks?
• D&E
• induction
• Take your cues
from mom
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Photo retrieved 1/13/14 from
•http://2.bp.blogspot.com/-MJoqqHG4RwI/UWXM7pKGXeI/AAAAAAAAAXI/cmPtjXj91Yo/s1600/Fundal+Height.gif
Most important lesson
Meet Marge
• 35
• G3P2
• Vaginal bleeding
• squad
• 32 weeks
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Domestic Violence
Each encounter
• Safety questions
• Hidden abuse
• Child safety
– Child not related to adult members
• Abdomen seems to be the preferred site during
pregnancy
Recreational Drugs
• Use is increasing
• Baby is not born addicted—born dependent
• Withdrawal of newborn
• Nicotine withdrawal- day 3
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Abruptions
• Partial
• Complete
• Hidden
• 800 mL/min uterus
• Dislodge the placenta
Trauma
• Treat the mom
– She’ll treat the baby
• C-spine
– Tilt the board
• Seatbelt use
– Above the uterus, low on hips
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Back to Marge
• Home on bedrest
• Known placenta previa
• Vaginal bleeding
Take away
• Large bore IV’s
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Terry and her DKA
• Type I diabetes
• Non-compliant
• Multiple ER visits
• Didn’t believe
• Didn’t want
• Didn’t care
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Placenta is not a filter
• Molecular size plays
a part
– Glucose crosses
– Insulin does not
• Baby’s get big
– Weight distribution
unequal
– Lung maturity delayed
• Glucose supply gone
with delivery
Implications for Delivery
Retrieved from http://blogs.babble.com/being-pregnant/files/2011/03/16-lb-big-baby.jpg
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Preeclampsia
• Task Force on Hypertension in Pregnancy
– Summary of findings, October 2013
• Chronic Hypertension
• Preeclampsia/eclampsia
• Chronic HTN with superimposed preeclampsia
• Gestational HTN
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Eliminated the Dependence upon Protein
• In the absence of protein: Diagnosis is HTN in
association with
• Thrombocytopenia
• Impaired liver function ( twice normal)
• New development of renal insufficiency
• Serum creatinine >1.1 mg/dL or doubled in absence of
renal disease
• Pulmonary edema
• New onset cerebral or visual disorders
• Severe features S ≥ 160 D ≥ 110
Best Practice
• No LIGHTS
• No SIRENS
• No DRAMA
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Magnesium Sulfate
• 4-6 gms over 30 min
• Respiratory depression
• Loss of DTR’s
• Cardiac monitoring
What do you worry about?
• Eclampsia
• Seizures
• Stabilize the mom….then deliver the baby
• Can happen post delivery-up to 12 weeks
911
• Pregnant female, rapid labor
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Cardinal Movements
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•You are going to have to look
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Check the Neck
• Slip over the head
• Slip down the body
• Somersault the baby out
• Too tight?
• Clamp in 2 places and cut between clamps
• Nightmare
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Turtle Sign
Who is at risk
• Previous shoulder dystocia
• Large babies
• Diabetic mothers
• EVERYBODY
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Hands and knees
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Convection: transfer of heat to air
moving across and around body
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Radiation: transfer of heat between 2 objects
that are not in direct contact. Heat is
transferred from the warmer object to the
cooler one.
Conduction: transfer of heat
between 2 solid objects that are in
direct contact
Evaporation: heat loss by
conversion of liquid usually water
into vapor.
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Kangaroo Care
Breastfeeding
Photo retrieved from http://www.associatedobgyn.net/wp-content/uploads/2012/01/Breast-Feeding-Baby.jpg
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Skin to Skin and What about Dads?
Personal photo bank
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Evaluating the Newborn
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Apgars
• Does not dictate resuscitation
– 1 min
– 5 min
• Well flexed extremities
• Spontaneous respirations
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•All about respiration
– Stimulate to breathe
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IF……Suction mouth and nose
• O2-small ambu bag
• Chills baby
• 2 finger compression
• Heartrate less than 60
What if you see…….
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Life lesson #411
•What do you look for after you
deliver a baby?
What about that placenta?
• Separation within 30-60 mins of birth
– Perfect world- 10 to 15 minutes
• No pulling on cord
• Gush of blood with separation
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Bleeding post placenta
• Fundal/uterine massage
• Pitocin
• Breastfeeding
• Cytotec
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Fundal massage
Postpartum hemorrhage
• Uterine Atony
• Retained products of conception
• Infection
• Multiples
• Clotting disorder
Delivery
• 500 mL- vaginal delivery
• 1000 mL C/S delivery
• Amniotic fluid
• Subjective Blood loss
• Soaking of the pads
• Measure = Save
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Postpartum Hemorrhage
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Hemorrhage Cart
http://www.disease-picture.com/wp-content/uploads/2011/12/21/textbook-of-postpartum-hemorrhagero.jpg
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Intrauterine Balloon
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Uterine Artery Embolization
Retrieved from http://www.natural-homeremedies.com/blog/wp-content/uploads/2012/06/Uterine-Artery-Embolization.jpg
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Obstetric Drills
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Shoulder dystocias
Hemorrhage
Seizures
Cord prolapse
• House wide
•http://www.scvmc.org/professionals/residency/obgyn/PublishingImages/OBDrillsPostpartumHem.jpg
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Questions??
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References
• Definition of Term Pregnancy. (Nov, 2013). Committee Opinion Number
579. ACOG, Society for Maternal-Fetal Medicine.
• Driggers, R., Seibert, D., (May, 2008). The Journal for Nurse
Practitioners. 351-356.
• Guidelines for Perinatal Care 7th Edition. (2012). American Academy of
Pediatrics & American College of Obstetricians and Gynecologists.
• Inherited Thrombophilias in Pregnancy. (Sept, 2013). Practice Bulletin
Number 138. ACOG.
• Management of Preterm Labor. (June, 2012). Practice Bulletin Number
127. ACOG.
• Opioid Abuse, Dependence, and Addiction in Pregnancy. (May, 2012).
Committee Opinion Number 524. ACOG, Committee on Health Care for
Underserved Women and the American Society of Addiction Medicine.
• Simpson, K.R., Creehan, P. A., Perinatal Nursing, 4th Ed., AWHONN,
Wolters Kluwer, 2013.
• Premature Rupture of Membranes. (Oct. 2013). Practice Bulletin Number
139. ACOG
• The Use of Chromosomal Microarray Analysis in Prenatal Diagnosis.
(Dec. 2013). Committee Opinion. ACOG
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