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Dr. A.


Case based studies to learn the evaluation and management of OB emergencies

34 yr old G1P0 presents at 41 w 4 days for postdates induction. Cervix is 1 cm / long / -2. Uncomplicated pregnancy. PMH: NAD

0900 1700 Misoprostil x 3 doses vaginally 1900 Regular UCtx 2 cm / 25% / -2 2300 Regular UCtx 4 cm / 50% / -1 0400 Regular UCtx 4 cm / 60% / -1 0430 Pitocin started

0800: 8 cm / 90% / 0 1100: complete 1250: OA Delivery infant boy 3790 grams 1325: Delivery of placenta. Moderate bleeding responds to bimanual massage. 1340: 2nd degree perineal tear repair done 1344: Mild bleeding intermittently 1430: P increase 102 to 125. Feels lightheaded. MD called back to room

Defined as >500 ml blood loss vaginal or >1000 ml blood loss after c-section or Hemodynamic instability

Lightheadedness / Tachycardia / Hypotension / Syncope

HCT drop > 10 Need for blood transfusion

Risk factors


Pre-eclampsia Multiparity Multiple gestation Previous PPH Previous C-section Pitocin augmented / induced labor Prolonged third stage Instrument assisted vaginal delivery Shoulder dystocia Episiotomy / Laceration


Management of anemia in pregnancy Appropriate labor management

Appropriate pt selection for induction Third stage management

Think of the 4 Ts: Tone decreased uterine tone most common cause Trauma Laceration / Uterine inversion Tissue retained placental tissue Thrombin depleted coagulation factors

Pitocin 20 units in 1 liter LR. IV bolus beginning with delivery of anterior shoulder of infant Massage uterus Inspect vaginal vault / cervix / placenta

If not responding to above measures:

Methergine 0.2 mg IM. Can repeat every 6-8 hrs.

Contraindication: HTN disorders

Carbaprost (Hemabate) 0.25 mg IM

Contraindication: RAD

Misoprostil 1000 mcg PR x 1

Failure to deliver placenta in 30 minutes Treatment:

Gentle cord traction Consider injection of 20 units of pitocin in the umbilical vein (2 ml of pitocin in 20 ml saline) Manual extraction

Manual extraction:
Consider uterine relaxation (halothane / nitroglycerin 50 mcg IV / terbutaline 0.25 mg SQ. Bleeding will be a problem if you do this. You will need to reverse it afterward. Consider sedation (If no epidural) (Fentanyl) Find the cleavage plane b/t placenta and uterus Advance fingertips cleaving the placenta free. If no cleavage plane, consider placental insertion problem and need for OR

Retained placenta due to abn implantation

Placenta accreta
Firm attachment to myometrium. 4% of previas have


Placenta increta
Invasion of myometrium.

Placenta percreta
Invades through myometrium.

Rare Cause: Uterine atony / congenital weakness of uterus / ? Undue cord traction Prompt recognition: What the heck is that? Do not remove the placenta use your fist to replace the uterus in the pelvis

Uterus not replaceable due to contraction ring:

Nitroglycerin 100 mcg IV

If this fails, needs to go to OR for general anesthesia

Treat cause Maintain fibrinogen > 100 mg / dl with FFP / Cryoprecipitate Maintain Plt count > 50,000 Specific factor replacement for known coagulation diseases

27 yr G1P0 is in active labor. Her pregnancy was uncomplicated. She was complete at 1300. At 1415 she delivers an OA Head over an intact perineum. A turtle sign is noted. You suction the fetal mouth and nose and then assist restitution of the head. Despite maternal pushing, you are unable to deliver the head over the next minute.

What do you do next?

Definition: Delivery in which the anterior shoulder of the baby is impacted against the maternal symphysis pubis and is not deliverable in 60 seconds. Common!!! Risk Factors - ???

Risk Factors
Prior shoulder dystocia Diabetes Prolonged gestation Fetal macrosomia Maternal obesity

Fetal macrosomia
Fetal wt 2500 4000 gm: 0.3 1% (Note that 50% of shoulder dystocias occur in this group) Fetal wt > 4000gm ---> RR 11 Fetal wt > 4500gm ---> RR 22

EFW . Clinical Vs US


Maintenance of good glycemic control in pregnant diabetic women decreases fetal macrosomia Elective C-section for fetal macrosomia?

Elective C-section for EFW >4500 grams in nondiabetic women

3600 C-sections to prevent one permanent brachial plexus injury


Help (call for) Episiotomy (consider) Legs (McRoberts Maneuver) Pressure (suprapubic) Enter vagina (Internal maneuvers) Remove the posterior arm Roll the patient

McRoberts position


Enter vagina
Rotate anterior shoulder (Apply pressure to posterior

aspect of shoulder) Woods screw maneuver: Apply pressure to the anterior aspect of the posterior shoulder while continuing to rotate the anterior shoulder also. Reverse Woods screw maneuver

Remove posterior arm Roll pt onto hands / legs Last resort measures
Fracture clavicle Zavanelli maneuver Hysterotomy Symphysiotomy

27 yr female G2 P1 at 40 w in spontaneous active labor. She complains of mod pain in between her contractions that was relieved with her epidural. Mild bleeding with contractions. PMHx: uncomplicated Social Hx: uncomplicated/normal/low risk

On exam, Cx is 8-9cm / 100% / - 1 station Presentation is vertex Position is straight OA Last BP was 155/93 after a contraction Last Pulse was 100 Urine no protein Fetal strip Baseline 140 Good longterm variability Noted variable decels to 110

What are your concerns? Ddx? How would you manage this patient?

Placenta abruption Placenta previa Vasa previa Uterine rupture

Painful third trimester bleeding. 1:120 pregnancies, approx. 1%. Recurrence rate of 10%. Port wine stained amniotic fluid.

Hypertensive diseases of pregnancy Trauma Drug use - cocaine Smoking/poor nutrition Twins/polyhydramnios

Trauma - 2 large bore IVs for IVF / blood products as needed. Labs: CBC / Type and screen / Coags Tape a red top tube to the wall and check for spontaneous clotting Consider ultrasound depending on clinical presentation - must have 200-300cc blood to be visible. If no prior U/S, you need to r/o placenta previa

If term, then deliver. Consider controlled induction if patients are stable. If preterm, weigh risks of continued pregnancy against risks of complications from preterm delivery.

Painless third trimester vaginal bleeding 1:200 pregnancies in 3rd trimester 1:50 grand multiparas,1:1500 nulliparas Risks:

Prior c-section Prior uterine instrumentation High parity


C-section Vaginal delivery can be considered under a double setup status in the OR


What is the role of the digital vaginal exam?

Fetal vessel crosses presenting membranes (velamentous insertion) Occurs in pregnancies with low lying placenta Rare (1:3000) Bleeding is fetal Mortality is high


Membrane palpation before amniotomy

Wright stain: Blood from vagina.

Look for nucleated rbcs

Apt test: Mix blood from vagina with tap water. Mix with NaOH.

Fetal Hgb: pink Maternal Hgb: brown

Kleihauer Betke test

No role in diagnosis of abruption or vasa previa (slow test) Sample: maternal blood Make smear Stain for cells with fetal hemoglobin
Used to calculate dose of Rhogam in fetomaternal hemorrhage

Major risk is prior c-section Warning sign: Variable deceleration

Do not take lightly in a TOL patient

17 yr old G1P0 presents at 37 w 1 day with complaint of HA / nausea / upper abdominal pain. RN notes BP 170 / 115 RN pages you to L&D Within 5 seconds of your arrival, the pt has an obvious seizure

What do you do?


BP > 140 systolic or > 90 diastolic on two occasions more than six hours apart. Proteinuria of > 300 mg / 24hours

Affects 5-8% of pregnancies Risk factors include first pregnancy, multiple gestation, chronic HTN, pregestational diabetes.

BP >160 / 110 Proteinuria > 5 grams / 24 hours Oliguria (<500 ml urine / 24 hours) Elevated Cr Pulmonary edema HELLP syndrome Symptoms indicating other end organ damage (RUQ pain / HA / Visual change) or Seizure (Eclampsia)

Seizure in pregnancy at or near term usually associated with Pre-eclampsia May occur up to 48 hours after delivery. 70% intrapartum / 30% postpartum. Risk factors Similar to Pre-eclampsia 1:150 - 1:3500

Protect the airway Get Help Magnesium sulfate 6 grams IV over 20 minutes. Start gtt at 2gm/hr. If already on Magnesium sulfate, immediately bolus 2 grams IV over 20 minutes. Oxygen Benzos?

What do you do when the seizure is over?

Review of common findings on fetal monitoring

24 yr old G2P1 at 41 weeks. Post-dates NST:

What is the expected outcome of this pregnancy?