Maternal Resuscitation and Post-Partum Hemorrhage – ALSO

Physiological Changes with Pregnancy
–  Cardiovascular
    –  Uterus gets 20-30% of cardiac output.
    –  Volume and RBC expansion begins about 4 wks, peaks at 28-34 weeks, declines to delivery.
    –  Larger relative increase in plasma volume vs RBCs –> decrease in HCT to nadir 24-26 weeks.
    –  Lower peripheral vascular resistance, increased cardiac output.
–  Gastrointestinal
    –  Delayed gastric emptying –> more likely to have food in stomach!
–  Pulmonary
    –  Increased minute ventilation, so increase in PaCO2 very worrisome!
ABCs
– Airway w C-spine – protect C-spine and ensure patent airway, place definitive airway in secondary survey.
– Breathing – rescue breaths, supplemental O2 and ventilation in secondary survey.
– Circulation – chest compressions, IV access, volume resuscitation in secondary survey.
  – Do chest compressions with pt rolled to maternal L side (off IVC), human wedge, or…
  – Keep patient supine and manually displace uterus to the left – optimal chest compression vectors.
– D: Defibrillate (mono 360J, biphasic 200J) and DDx:  ; consider DDx (Hs and Ts) in secondary survey.
The Four-Minute Rule:  Due to the avidity of fetal hemoglobin, the fetus has about 2 minutes of O2 reserves in a pulseless and apneic mother.  Consider perimortem C-section after 4 minutes of unsuccessful resuscitation IF:
   –  Fetus viable (>23-24 weeks) AND
   –  Facilities to care for premature/sick neonate available.
** Perimortem C-section not only can save baby – can lead to improved chances for mom!
 
Amniotic Fluid Embolism
–  Sudden, catastrophic syndrome of cardiac, pulmonary and inflammatory pathophysiology.
–  DDX:  massive PE, septic shock, acute MI with cardiogenic shock, eclampsia, bilateral PTX, uterine rupture
   or inversion.
 
Motor vehicle accident:
–  Proper seatbelt use should be encouraged – reduces traumatic injury.
–  MONITORING POST-MVA:  Monitor for contractions if >20 weeks (above umbilicus):
   –  If < 3/hour, monitor for 4 hours then D/C home if stable.
   –  If > 3/hour, monitor for 24 hours.
–  DISCHARGE IF:  no ROM, reassuring FHT, contractions resolve, no VB or uterine tenderness.
Active Management of the Third Stage of Labor:
–  Oxytocin – with or soon after delivery, PRIOR to placental separation (breastfeeding if oxytocin refused!)
–  Early cord clamping
–  Gentle, continuous tension on cord WITH BRANDT MANEUVER (to avoid inversion)
–  Uterine massage after placenta delivers
Systematic Review:  7 trials, 8427 women – reduced risk of severe PPH (>1000mL, RR 0.34) and blood loss >500mL (RR 0.34), anemia after delivery, need for transfusion or need for uterotonics in first 24 hours.  Active management associated with DBP >90 mmHg, increased afterpains and use of analgesia (RR 2.53) and increase return to hospital with bleeding (RR 2.51).
Post-Partum Hemorrhage
TREAT LIKE A TRAUMA:  ABCs, 2 large-bore IV, check CBC, type & cross 4-6 units pRBC, IVF 2 L NS or LR.
–  Meds:
  – Oxytocin 10 units IV or IM, 10-40 units in 1L NS at 250 cc/h
  – Methergine (methylergonovine) 0.2 mg IM (NOT IN HTN)
  – Hemabate (prostaglandin F2a) 0.25 mg IM or intermyometrial q 15 mins x 8 doses
  – Misoprostol 800-1000 mcg PV/PR or 600 mcg PO/SL
–  Pelvic Interventions
  – Uterine massage
  – Empty bladder
  – Four Ts
    – Tone – uterine atony (70%) – drugs and massage
    – Trauma – cervical and vaginal lacerations (20%), inversion or rupture
    – Tissue – retained placenta – sweep
    – Thrombin – coagulopathy (ITP, TTP, vWB, DIC) – consider FFP, platelets
–  Go to surgery if bleeding persists!
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