Role of Nurse in Obstetric Emergencies

 

Prof. Reeta Jebakumari¹, Dr. Nalini Jayavanth Santha²

¹Principal, Thasiah College of Nursing, Marthandam

²Research Guide and Principal Sacred Heart Nursing College, Madurai

 

ABSTRACT:

Obstetric emergencies are existence of sudden obstetrical event which requires immediate action. they are life threatening medical conditions that occur in pregnancy, during or after labor and delivery. few important obstetrical conditions which could cause obstetrical emergencies are placenta previa ,abruptio placenta,eclampsia ,rupture uterus, prolapsed cord postpartum hemorrhage.obstetrical emergencies can be caused by a number of factors, including stress, trauma, genetics, and other variables.Signs and Symptoms: Diminished fetal activity. in the late third trimester, fewer than ten movements in a two hour period may indicate that the fetus is in distress. Abnormal Bleeding: During pregnancy, brown or white to pink vaginal discharge is normal, bright red blood or blood containing large clots is not. after delivery, continual blood loss of over 500 ml indicates hemorrhage. Leaking Amniotic Fluid: Amniotic fluid is straw-colored and may easily be confused with urine leakage, severe abdominal pain. stomach or lower back pain can indicate preeclampsia or an undiagnosed ectopic pregnancy. postpartum stomach pain can be a sign of infection or hemorrhage. Contractions: Regular contractions before 37 weeks of gestation can signal the onset of preterm labor due to obstetrical complications. abrupt and rapid increase in blood pressure. hypertension is one of the first signs of toxemia. Loss of Consciousness. Shock due to blood loss (hemorrhage) or amniotic embolism blurred vision and headaches. vision problems and headache are possible symptoms of preeclampsia. Role of obstetrical care practitioner: the immediate management of the emergency is dependent on the prompt action of the midwife recognition of the problem and the investigation of measures allow time for help to arrive. she needs to recognize the onset of complications perform intervention and treatment she needs to have cognition practical skills that enables her to give emergency obstetrical care including life saving measures when needed being technically up-to-date on the latest evidence based skills having current proficiency in these skills the success of midwife lies in identifying those who are at the potential risk and referring them for expert care. and also being competent in executing emergency measures.

 

 

 

 

 

 

INTRODUCTION:

More than 80% of maternal deaths worldwide are due to five direct causes haemorrhage, sepsis, unsafe abortions and obstructed labour. The speed of the prompt action while calling for medical aid often help to determine the outcome for the mother or baby. The immediate management of these causes depend on the prompt action of the midwife. Recognition of the problem and the investigation of emergency measures allow time for help to arrive

 

Definition of Obstetrics Emergencies:

Definition:

·        Obstetric emergencies are existence of sudden obstetrical events which require immediate action¹.

·        They are life threatening medical conditions that occur in pregnancy, during or after labor and delivery.

 

Emergency Situations:

The different emergency conditions which can occur during antenatal, intranatal and post natal period are given below

 

 

 

Role of Obstetric Nurse in Preparing the hospital for Clinical Emergencies²

1.      Planning

2.      Advance Provision of Resources in the Outpatient Setting

3.      Early Warning Systems in the Inpatient Setting

4.      Rapid Response Team

5.      Emergency Drills and Simulation

 

Preparing for Obstetric Emergencies:

 

 

 

1. PLANNING -Assessment of actual/potential risks²:

Outpatient Setting – Medications given Procedures performed

Inpatient Setting – Risk management data Common AND Uncommon emergencies occurred

 

2. Advanced Provision of Resources:

·        Be familiar with crash cart/emergency trolley

·        Placing all necessary items

·        Replacing after each use

·        Incidence based changes

·        Advance provisions of resources

 

Ex: PPH Box:

·        To be checked daily

·        Ensure that perishable supplies have not been retained beyond expiration date

 

3. Early Warning System:

·        Rapid response team

·        Protocol

·        Emergency Communication process

 

4. Rapid Response Team³

·        Team of Critical Care expertise to patients bedside or wherever it is needed

·        Standardized Communication Tool : SBAR tool

·        Situation, Background, Assessment AND Recommendation

·        Initiation Phase

·        Response Phase

·        Action Phase

 

5. Emergency Drills AND Simulations:

·        To practice principles of effective communication in crisis.

·        To improve standardization of response, health care provider satisfaction and patients outcome

 

Few important obstetrical conditions which could cause obstetrical emergencies are listed below.

1)     Placenta Previa

2)     Abruptio Placenta

3)     Eclampsia

4)     Rupture Uterus

5)     Prolapsed cord

6)     Postpartum Hemorrhage

 

1. Placenta previa⁴:

·        It is the improper implantation of the placenta in the lower uterine segment.

·        It is classified according to the degree to which the placenta covers the cervical os.

·        Low-lying

·        Marginal

·        Partial

·        Complete or Total

 

 

 

Causes:

—  Multiparity (80% of affected clients are multiparous)

—   Advanced maternal age (older than 35 years old in 33% of cases

—  Multiple gestation

—  Uterine Incisions

 

Clinical Manifestations:

·        Episodic painless vaginal bleeding after 20 weeks gestation

·        Bright Red Bleeding without uterine contractions

·        Ultrasound:

·        Reveals the malpositioned placenta

 

Complications of placenta previa:

·        Preterm delivery

·        Hypovolemia

·        Altered tissue perfusion

·        Deterioration in fetal status

 

Nursing Care:

·        Perform a complete assessment on any pregnant mother who presents with painless bright red vaginal bleeding

 

NO VAGINAL EXAMS:

Insert large bore needle (18 or greater) and maintain IV infusion

 

Monitor:

·        Vital signs

·        Continuous Fetal monitoring

·        I AND O, pad count/weight them

Notify:

Physician, charge nurse, ICN, and anesthesia personnel

 

Placenta Previa-Nursing Diagnosis⁵:

Decreased cardiac output related to:

Excessive blood loss secondary to placenta previa

 

Deficient fluid volume related to:

Excessive blood loss secondary to placenta previa

 

Risk for excessive fluid volume related to:

Fluid resuscitation

 

Ineffective peripheral tissue perfusion related to:

Hypovolemia AND shunting of blood to central circulation

 

Risk for injury (fetal) related to:

Decreased placental perfusion secondary to placenta previa

 

Anticipatory grieving related to:

Actual /perceived threat to self, pregnancy, or infant

 

2. Abruptio Placenta⁴:

·        It is a premature separation, either partial or total of a normally implanted placenta from the decidual lining of the uterus after 20 weeks’ gestation.

·        Classifications of Abruptio Placenta:

 

Types:

·        Revealed

·        Concealed

·        Complete

 

 

 

Risk Factors:

·        Preeclampsia

·        Eclampsia

·        Chronic Hypertension

·        Multiparty

·        Abdominal Trauma

·        Uterine Anomalies

·        Smoking

·        Cocaine Abuse

·        Premature Rupture Of Membranes-PROM

 

Clinical manifestations:

·        Sudden Dark Red Vaginal Bleeding

·        Unremitting pain

·        Ultrasound will show abruption

·        Uterine irritability

·        No reassuring Fetal Heart pattern- Loss of variability and late decelerations

 

Complications of Abruptio Placenta:

·        Risk of depleting clotting factors

·        DIC

·        Hypovolemia

·        Multi organ failure

·        Maternal Death

·        Uterine Placenta insuffiency

·        Fetal Hypoxia

·        Fetal Death

 

Nursing Care:

Assess and Monitor:

·        Amount of Vaginal Bleeding

·        Vital Signs

·        I AND O

·        Measure abdominal girth

·        Uterine characteristics and activity

·        EFM-Continuously

·        For development of coagulation problems

·        Review lab values:

·        CBC, Coagulation studies, PT, PTT

 

Nursing Care⁶:

·        Insert large IV Catheter(18-gauge or bigger) and maintain IV infusion

·        Provide Oxygen at 8-12 L/min

·        Prepare for Transfusion Therapy

·        Anticipate Expedited Delivery:

·        Vaginally

·        Cesarean section

 

3. Eclampsia⁵

Pre-eclampsia when complicated with generalized tonic-clonic convulsion and /or coma is called Eclampsia .

 

TONIC- CLONIC CONVULSION SIGNS:

Ÿ  Stage of invasion 2-3 sec, eyes are fixed, twitching of facial muscles occur.

Ÿ   Stage of contraction: 15-20 sec, eyes protrude and are blood-shot, all body muscles are in tonic contraction.

 

Nursing Intervention:

·        Keep the airway patent: Turn head to one side

·        Call for assistance

·        Protect with side rails AND prevent injury

·        Observe and record convulsion activity.

 

After Convulsion Or Seizure:

·        Administer oxygen via face mask at 10L/min

·        Star IV fluids and monitor for potential fluid overload

·        Use suction as needed

·        Give magnesium sulfate or anticonvulsant drug as ordered

·        Insert indwelling urinary catheter

·        Monitor blood pressure

·        Monitor fetal and uterine status

·        Expedite laboratory work as ordered to monitor kidney AND liver function

·        Deliver by 6 – 8 hrs

 

Reportable Conditions:

·        BP systolic > 160 mm Hg diastolic > 110 mm Hg

·        Funduscopic evidence of arteriospasm, retinal detachment AND hemorrhage

·        Urinary output < 30ml/hr

·        Presence of head ache, Visual disturbance/ epigastric pain

·        Increase or loss of deep tendon reflex, increase edema, proteinuria

·        Change in maternal AND fetal status

 

Emergency Measures:

·        Keep emergency tray with Calcium gluconate

·        Keep Side rails up

·        Keep lights dimed AND maintain quiet environment

 

4. Rupture Uterus:

Definition:

During labor, a weak spot in the uterus such as scar or a uterine wall that is thinned by a multiple pregnancy may tear resulting in a uterine rupture

 

TYPES:

Complete 

Incomplete

 

NURSING CARE:

·        I/V infusion with big bore needle

·        Transfusing blood products

·        Administering oxygen

·        Assisting with the preparation for immediate surgery

·        Supporting the woman’s family AND providing information

 

5. Prolapsed Cord:

A prolapsed of the umbilical cord occurs when the cord is pushed down into the cervix / vagina.

F the cord becomes compressed, the oxygen supply to the fetus could be diminished, resulting in brain damage or possible death.

 

Signs:

·        Fetal bradycardia with variable declaration

·        Cord is seen or protruding from the vagina

 

Prolapsed Cord:

Nursing Interventions⁶:

·        Call for assistance.

·        Insert 2 fingers into the cervix. With one finger on either side of the cord exert upward pressure against the presenting part to relieve compression of the cord. Place a rolled towel under the woman’s right/left hip

·        Place the woman into the trendelenburg position or modified sim’s position or knee-chest position.

·        If the cord is protruding out wrap in sterile towel saturated with normal saline

·        Administer oxygen

·        Monitor FHR

·        Prepare for vaginal delivery if cervix is fully dilated or cesarean birth if it is not

 

 

 

6. POSTPARTUM HEMORRHAGE⁴:

Definition:

According to American college of Obstetrics AND Gynecology PPH is defined as blood loss of greater than 500 ml with a vaginal delivery or greater than 1000 ml with a cesarean section or a 10% drop in the hematocrit.

 

Types of PPH:

—  Immediate/primary PPH (occurs within 24 hrs of delivery)

1. Third stage hemorrhage

2. PPH after 3^rd stage

—  Late/secondary PPH- occurs after 24 hrs ans within 6 wks/upto 12 wks (ACOG practice bulletin, 2007)

 

Causes ans Predisposing factors of primary PPH

1. Tone:

Uterine atony

 

2. Tissue:

Retained placental tissue

 

3. Trauma:

—  Large episiotomy

—  Lacerations of perineum,vagina,cervix

—  Ruptured uterus

 

4. Thrombin:

 

 

Nursing Diagnosis- PPH⁵

Deficient fluid volume related to

Excessive blood loss secondary to uterine atony, laceration, or uterine inversion.

 

Risk for imbalanced fluid volume related to

Blood ans fluid volume replacement therapy

 

Risk for injury related to:

·        attempted manual removal of retained placenta

·        administration of blood products

·        operative products

 

Fear /anxiety related to

·        threat to self

·        deficient knowledge regarding procedures ans operative management

·        Ineffective peripheral tissue perfusion related to

·        excessive blood loss ans shunting of blood to central circulation

 

CONCLUSION:

Knowledge is the base and strength. The midwife need to have adequate knowledge about the obstetric emergencies and able to identify those who are at potential risk and referring the mothers for expert care. Following the ‘A, B, C, D’ given below will help the midwife to be successful in managing the obstetrical emergencies.

 

Act Promptly

Be alert to identify the onset ans Be familiar with recent evidence based, technical skills

Care with concern

Document accurately

Execute emergency measures with competence

 

REFERENCE:

1.       Dutta, D. C. (2008). Text book of Gynecology.(6^th ed.). London: New central book agency

2.       Dacey, Wilcox (2011). Preparing for clinicalEmergencies in Obstetrics ansGynecology, Journal of Perinatalcare 35: 2076-82 Retrived from http://www.pnjournals.com/clinicalemergencies/obs ans Gyne/2076-82.

3.       Gosman, Nelson (2010). Establish a rapid response team required from http://www.ihi.org/criticalcar/establish rapidresponseteam.htm.

4.       Pilliteri, A. (2006).Manual and child Health Nursing – care of child bearing and child rearing family. (5^th Ed.). Philadelphia: Lippincott Company

5.       Lowdermilk, ans Perry. (2008). Maternity and Women’s Health care.(8^th ed.). New York : Mosby company

6.       Bennet and Brown. (2008). Myles text book of Midwives. (15^th edition).Philadelphia: Churchil Livingston.

 

Net Reference:

•         http://calsprogram.org/manual/volume3/Section22/OB15-ThirdStagePostpartum.html

•         http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2008/Sep5(3)/Pages/85.aspx

•         http://www.alsg.org/uk/MOET

•         http://en.wikipedia.org/wiki/Obstetrics

 

 

 

 

 

 

 

Received on 06.11.2017       Modified on 02.02.2018

Accepted on 02.04.2018    ©A&V Publications All right reserved