Obstetric and Gynecologic Emergencies

CHAPTER 22 Obstetric and Gynecologic Emergencies



Kathleen Sanders Jordan, RN, MS, FNP, APRN, BC



MAJOR TOPICS



General Strategy


Assessment

Analysis: Differential Nursing Diagnoses/Collaborative Problems

Planning and Implementation/Interventions

Evaluation and Ongoing Monitoring

Documentation of Interventions and Patient Response

Age-Related Considerations

Specific Obstetric Emergencies


Spontaneous Abortion

Placenta Previa and Abruptio Placentae

Ectopic Pregnancy

Pregnancy-Induced Hypertension: Preeclampsia; Eclampsia; and Hemolysis, Elevated Liver Enzymes, Low Platelets

Hyperemesis Gravidarum

Postpartum Hemorrhage

Emergency Delivery

Neonatal Resuscitation

Specific Gynecologic Emergencies


Vaginal Bleeding/Dysfunctional Uterine Bleeding

Pelvic Pain

Vaginitis

Sexually Transmitted Diseases

Pelvic Inflammatory Disease


I. GENERAL STRATEGY



A. Assessment




1. Primary and secondary assessment/resuscitation (see Chapter 1)


2. Focused assessment


a. Subjective data collection

1) History of present illness/chief complaint
a) Last normal menstrual period (LNMP): female patients of childbearing age

b) Positive pregnancy test: date and method (serum or urine)

c) Expected date of confinement (EDC)

d) Vaginal bleeding: amount, color, presence of clots/tissue, number of full pads/tampons used (each holds approximately 30 mL of blood)

e) Vaginal discharge: amount, color, quality, odor, itching, burning

f) Pain (see Chapter 9): abdominal/pelvic pain: provocation, quality, radiation, severity, timing

g) Nausea and vomiting

h) Fever/chills

i) Visual disturbances, headache, sudden weight gain, dependent/generalized edema

j) Change in fetal movement

k) Rupture of membranes: time, color, and odor

l) Uterine contractions: onset, frequency, severity

m) Urinary frequency, dysuria, urgency, hematuria

n) Trauma: mechanism of injury (see Chapter 30)

o) Efforts to relieve symptoms
(1) Home remedies

(2) Alternative therapies

(3) Medications
(a) Prescription

(b) Over-the-counter/herbal

2) Past medical history
a) Current or preexisting diseases/illness
(1) Cardiovascular disease

(2) Deep venous thrombosis

(3) Pulmonary disease/emboli

(4) Hypertension

(5) Diabetes

(6) Thyroid disease

(7) Renal disease/urinary tract infections

(8) Immunosuppression disease

b) Reproductive history: all pregnancies with dates (include premature deliveries, spontaneous abortions/therapeutic abortions, full-term deliveries, living children)

c) Prenatal care if appropriate

d) Date and type of delivery, if post partum

e) Abdominal/pelvic surgery

f) Sexual activity/preference: new sexual partner within last 2 months or multiple sexual partners within last 6 months, high-risk behavior

g) Contraceptive use

h) Sexually transmitted diseases (STDs)/pelvic inflammatory disease (PID), hepatitis and human immunodeficiency virus (HIV) status

i) Smoking history

j) Substance and/or alcohol use/abuse

k) Current medications
(1) Prescription

(2) Over-the-counter/herbal

l) Allergies

m) Immunization status

3) Psychological, social, environmental factors
a) Age: consider possibility of pregnancy in women 12 to 55 years old

b) Nationality/ethnicity

c) Occupation

d) Economic capabilities and resources

e) Social support system

f) Nutritional status

g) Genetic history

h) Possible/actual abuse, assault, or intimate partner violence situations (see Chapter 3)

b. Objective data collection

1) General appearance
a) Level of consciousness, behavior, affect

b) Vital signs: orthostasis; left lateral position if patient is 20 weeks’ or greater gestation to prevent supine hypotension syndrome

c) Odors

d) Gait

e) Hygiene

f) Level of distress/discomfort

2) Inspection
a) Edema: facial, peripheral or generalized

b) Skin: color

c) Abdominal or perineal wound site

d) Vaginal bleeding: color and amount, passage of clots or tissue

e) Amniotic fluid: color and pH (amniotic fluid is clear and pH neutral)

3) Auscultation
a) Bowel sounds

b) Fetal heart tones (FHTs) if gestational age greater than 13 weeks

4) Palpation
a) Abdominal tenderness, rebound tenderness

b) Uterine size, fundal height, irritability, contractility

c) Skin temperature, moisture

5) Pelvic examination
a) External genitalia inspection, noting excoriation, erythema, and vesicular lesions

b) Vaginal mucosa inspected for color, edema, discharge, lesions; urethra inspected, noting Bartholin’s and Skene’s glands for erythema, edema, and discharge, palpated for tenderness

c) Vagina and cervix inspected for lesions, erosions, ulcerations, bleeding, and discharge

d) Bimanual examination; uterus palpated for size, shape, consistency, cervical motion tenderness; adnexal tenderness, fullness, masses

3. Diagnostic procedures


a. Laboratory studies

1) Complete blood count (CBC) with differential

2) Coagulation profile: prothrombin time (PT), partial thromboplastin time (PTT), fibrinogen, fibrin split products

3) Serum chemistries including glucose, blood urea nitrogen (BUN) and creatinine

4) Urinalysis; pregnancy test: serum and/or urine female patients of childbearing age

5) Serum and urine toxicology screen

6) Erythrocyte sedimentation rate (ESR)

7) Type and crossmatch, Rh factor

8) Thyroid function tests

9) Liver enzymes

10) Arterial/venous blood gas

11) Kleihauer-Betke test: to assess and measure presence of fetomaternal hemorrhage

12) C-reactive protein: nonspecific method for evaluating severity and course of inflammatory diseases; positive C-reactive protein indicates presence of active inflammation

13) STD screening: Chlamydia infection, gonorrhea, hepatitis B, rapid plasma reagin, HIV infection

14) Wet mount: normal saline and potassium hydroxide (KOH) preparations

b. Imaging studies

1) Chest radiograph

2) Sonography: pelvic and/or transvaginal

3) Computed tomography (CT) scan

c. Other

1) 12- to 15-lead electrocardiogram (ECG)

2) Culdocentesis: performed infrequently

3) Cardiotocographic (electronic) monitoring: uterine contractions and fetal heart rate

4) pH level for amniotic fluid


B. Analysis: Differential Nursing Diagnoses/Collaborative Problems




1. Acute pain


2. Deficient fluid volume


3. Ineffective tissue perfusion


4. Anxiety


5. Fear


6. Risk for infection


7. Deficient knowledge


8. Anticipatory grieving



C. Planning and Implementation/Interventions




1. Determine priorities of care


a. Maintain airway, breathing, and circulation (see Chapter 1)

b. Provide supplemental oxygen as indicated

c. Establish intravenous (IV) access for administration of crystalloid fluid/blood products/medication as needed

d. Obtain and set up equipment and supplies

e. Prepare for/assist with medical interventions

f. Administer pharmacologic therapy as ordered

2. Relieve anxiety/apprehension


3. Allow significant others to remain with patient if supportive


4. Educate patient and significant others



D. Evaluation and Ongoing Monitoring (See Appendix B)




1. Continuously monitor and treat as indicated


2. Monitor patient response/outcomes, and modify nursing care plan as appropriate


3. If positive patient outcomes are not demonstrated, reevaluate assessment and/or plan of care



E. Documentation of Interventions and Patient Response




F. Age-Related Considerations




1. Pediatric


a. Growth or development related

1) Breast development signals the onset of puberty and usually occurs between the ages of 8 and 11 years

2) The average age of menarche is 13 years

3) Estrogen and progesterone production increase with puberty

4) At puberty, the uterus descends into the lower pelvis

b. “Pearls”

1) Child maltreatment must always be considered in the presence of gynecologic complaints; however, the physical examination in 75% to 85% of sexually abused children is normal. History is the most critical part of the evaluation, and a high index of suspicion must be maintained

2) Vulvovaginitis and vaginal discharges are common problems in prepubertal and pubescent girls, although the causes vary with age. The incidence of STDs in prepubertal children is increasing and mandates investigation for the possibility of sexual abuse. Other causes include poor hygiene with perineal contamination, chemical irritation (e.g., soaps, bubble bath, and douches), infections, allergic reactions, foreign body, and congenital anomaly

3) The highest rate of STDs is in sexually active adolescents; additionally, this group is also at high risk for PID and is least likely to experience or report symptoms. Developmental and psychosocial characteristics of adolescent female patients also increase risk of contracting PID

4) Pelvic pain in postmenarchal adolescents usually has the same causes as in adults. A common cause of pelvic pain in prepubertal girls is appendicitis

5) Teenagers have a high risk of complications during pregnancy, labor, and delivery

2. Geriatric


a. Aging related

1) Malignant disease should always be considered because it is the most important, although not the most common, cause of bleeding in this age group. Postmenopausal hormonal changes may be responsible for dysfunctional uterine bleeding (DUB)

b. “Pearls”

1) The amount of bleeding does not correlate with the severity of disease

2) Patients in this age group with vaginal bleeding are at increased risk for uterine cancer


II. SPECIFIC OBSTETRIC EMERGENCIES



A. Spontaneous Abortion


Spontaneous abortion is the loss of pregnancy before viability of the fetus defined as 20 weeks’ gestation or a fetus weighing less than 500 g. Spontaneous abortion should be considered in any woman of childbearing age who presents to the emergency department with vaginal bleeding. The incidence of spontaneous abortion in the United States is estimated to be 10% to 15% of all recognized pregnancies. Most occur before 8 weeks’ gestation; however, the true incidence of spontaneous abortion is much higher because many pregnancies terminate before diagnosis. The cause of spontaneous abortion is unknown in the majority of cases. Etiologic factors that have been implicated include chromosomal abnormalities, endocrine dysfunction, maldevelopment of the embryo, and trauma. Additional factors that increase an individual’s risk of spontaneous abortion include maternal infections, advanced maternal age, malnutrition, substance abuse, immunologic incompatibility, surgery during pregnancy, and structural anomalies of the reproductive organs. Spontaneous abortions are commonly categorized as threatened, inevitable, incomplete, complete, missed, or septic (Table 22-1).


Table 22-1 CLASSIFICATION OF SPONTANEOUS ABORTION
























Type Description
Threatened Slight vaginal bleeding and mild uterine cramping with a closed cervical os
Inevitable Moderate vaginal bleeding and moderate uterine cramping with an open cervical os, gross rupture of membranes
Incomplete Heavy vaginal bleeding and severe uterine cramping with an open cervical os and tissue in the cervix, incomplete expulsion of the products of conception
Complete Slight vaginal bleeding with mild uterine cramping with a closed cervical os, complete expulsion of the products of conception
Missed Slight vaginal bleeding and absent uterine contractions with a closed cervical os, prolonged retention of dead products of conception
Septic Malodorous vaginal bleeding/discharge and absent uterine contractions with a closed cervical os, fever, intrauterine infection



1. Assessment


a. Subjective data collection

1) History of present illness/chief complaint
a) Pain (see Chapter 9)
(1) Abdominal pain: crampy, severity variable

(2) Back pain, pelvic pressure

b) Vaginal bleeding: color, amount

c) Passage of clots or tissue

d) Positive pregnancy test: date and method

e) Fatigue, dizziness, lightheadedness, syncope

2) Past medical history
a) Current or preexisting diseases/illness

b) Gestational age: LNMP, EDC

c) Reproductive history

d) Contraceptive history

e) Prenatal care

f) Substance use/abuse

g) Medications

h) Allergies

b. Objective data collection

1) Physical examination
a) General appearance
(1) Possible positive orthostasis

(2) Mild to moderate distress/discomfort

b) Auscultation
(1) FHTs if gestational age greater than 13 weeks

c) Pelvic examination is mandatory to determine the amount and site of bleeding, presence of cervical dilation, and passage of tissue

2) Diagnostic procedures
a) Serum and/or urine pregnancy test: including quantitative serum human chorionic gonadotropin (β-hCG) level

b) CBC with differential

c) Type and crossmatch

d) Urinalysis

e) STD screening

f) Pelvic sonography to rule out ectopic pregnancy (EP), assess viability of fetus and gestational age, and diagnose retained products of conception

2. Analysis: differential nursing diagnoses/collaborative problems


a. Deficient fluid volume

b. Acute pain

c. Anticipatory grieving

d. Deficient knowledge

3. Planning and implementation/interventions


a. Maintain airway, breathing, and circulation (see Chapter 1)

b. Establish IV access for administration of crystalloid fluid/blood products/medication as needed

c. Prepare for/assist with medical interventions

1) Pelvic examination

2) Dilation and evacuation procedure

3) Assist with possible hospital admission

d. Administer pharmacologic therapy as ordered

1) Rh immune globulin (RhoGAM or Rhophylac) to all Rh-negative women

2) Oxytocin (Pitocin) or methylergonovine (Methergine) to control hemorrhage

3) Non-narcotic analgesics

4) Antibiotics

e. Educate patient and significant others

1) For threatened abortion, provide the following discharge instructions:
a) Maintain bed rest for 24 to 48 hours or until bleeding subsides

b) Pelvic rest (no sexual intercourse) until bleeding and cramping stop

c) Use sanitary pads only; avoid tampons

d) Return to emergency department if bleeding or pain increases

e) Save any clots or tissue that passes and bring to emergency department or follow-up physician

f) Ensure appropriate follow-up care with obstetrician

2) For complete abortion, provide the following discharge instructions:
a) Mild abdominal pain/cramping is commonly experienced for several days

b) Use sanitary pads only; avoid tampons

c) Take temperature four times per day

d) Take medications as prescribed
(1) Methylergonovine (Methergine)

(2) Non-narcotic analgesics

(3) Nonsteroidal anti-inflammatory drugs (NSAIDs)

(4) Antibiotics

e) Pelvic rest

f) Ensure appropriate follow-up care with obstetrician

g) Activity as tolerated

h) Return to emergency department if temperature is higher than 100.6°F (38.1°C) or bleeding, pain, or foul-smelling discharge occurs or increases

4. Evaluation and ongoing monitoring (see Appendix B)


a. Maternal hemodynamic status

b. Vaginal bleeding, passage of clots, tissue, products of conception

c. Pain relief


B. Placenta Previa and Abruptio Placentae


Placenta previa and abruptio placentae are the most serious causes of vaginal bleeding in the second and third trimesters of pregnancy. The end result of each of these conditions may be catastrophic for both mother and fetus. Placenta previa is a condition in which the placenta is abnormally implanted in the lower uterine segment and partially or completely obstructs the internal cervical os. It is estimated that approximately 45% of gravid women have a placenta previa during the second trimester of pregnancy; however, the incidence at term is less than 1%. This is because the lower uterine segment grows and stretches during the third trimester of pregnancy and causes the placental site to rise up the uterine wall away from the internal os. Softening of the lower uterine segment and effacement of the cervix in preparation for labor tear the implanted placenta previa, resulting in painless, bright red vaginal bleeding. Hemorrhage can result as the cervix continues to efface and dilate. The cause of placenta previa remains unknown. Associated etiologic factors include multiparity, multiple gestation, advanced maternal age, previous uterine scarring resulting from prior cesarean section birth or myomectomy, previous placenta previa, smoking, and placental abnormalities.


Abruptio placentae is an emergent obstetric condition that occurs when the placenta separates from its normal site of implantation before delivery of the fetus. The incidence is less than 3% of all pregnancies, although it is related to 15% of all perinatal deaths. Partial or complete separation of the placenta may occur, resulting in minimal to copious bleeding that may be seen vaginally or concealed behind the placenta. Damage to the vascular placental bed can cause a significant amount of blood loss, resulting in maternal hypotension and hypovolemic shock. The loss of placental circulation causes fetal distress or demise. Consumptive coagulopathy and progression to disseminated intravascular coagulopathy (DIC) may occur. The hallmark of abruption is vaginal bleeding with uterine tenderness or pain. The primary cause of placental abruption is unknown, but the following conditions have been suggested as etiologic factors: maternal hypertension, advanced maternal age, trauma (see Chapter 36), illegal drug use (e.g., cocaine), premature rupture of the membranes, short umbilical cord, uterine anomaly or tumor, pressure by the enlarged uterus on the inferior vena cava, low socioeconomic status, and dietary deficiency.




1. Assessment


a. Subjective data collection

1) History of the present illness/chief complaint
a) Bleeding: onset, duration, quantity, and character
(1) Placenta previa: sudden onset of bright red vaginal bleeding; may be profuse

(2) Abruptio placentae: dark red vaginal bleeding; amount variable because bleeding may be concealed

b) Pain (see Chapter 9): abdominal, pelvic, and/or back
(1) Placenta previa: usually absent

(2) Abruptio placentae: variable intensity

c) Gestational age (LNMP, EDC)

d) Maternal age: risks increased with advanced age

e) Recent trauma

f) Recent sexual intercourse

g) Decrease/loss of fetal movement

2) Past medical history
a) Current or preexisting diseases/illness

b) Multiparity

c) Premature rupture of membranes

d) History of placenta previa, abruptio placentae, previous cesarean section

e) Substance use/abuse

f) Smoking

g) Low socioeconomic status

h) Medications

i) Allergies

b. Objective data collection

1) Physical examination
a) General appearance
(1) Possible positive orthostasis

(2) Mild to moderate distress/discomfort, possibly critically ill

b) Auscultation
(1) FHTs

c) Palpation
(1) Abdominal tenderness, uterine tone, contractions

d) Perineal examination: evidence of bleeding (speculum or manual pelvic examination is contraindicated in second- and third-trimester vaginal bleeding until location of placenta is confirmed by sonography and placenta previa is ruled out)

2) Diagnostic procedures
a) CBC with differential

b) Coagulation profile: PT, PTT, fibrinogen level, fibrin split products

c) Type and crossmatch (at least four units packed red blood cells in hemorrhaging patient)

d) Kleihauer-Betke test

e) Serum chemistries

f) Pelvic sonography

g) Cardiotocographic monitoring (fetal monitoring)

2. Analysis: differential nursing diagnoses/collaborative problems


a. Deficient fluid volume

b. Ineffective tissue perfusion: maternal and fetal

c. Anxiety/fear

d. Anticipatory grieving

3. Planning and implementation/interventions


a. Maintain airway, breathing, and circulation (see Chapters 1 and 31)

b. Provide supplemental oxygen as indicated

c. Establish IV access for administration of crystalloid fluid/blood products/medications as needed

1) Infuse warmed normal saline solution fluid boluses

d. Maintain patient in left lateral decubitus position

e. Prepare for/assist with medical interventions

1) Emergency cesarean section

2) Emergency vaginal delivery and possible infant resuscitation

3) Assist with hospital admission and transport to labor and delivery unit when hemodynamically stable

f. Administer pharmacologic therapy as ordered

1) Rh immune globulin (RhoGAM or Rhophylac) to all Rh-negative women

4. Evaluation and ongoing monitoring (see Appendix B)


a. Maternal and infant hemodynamic status

b. Vaginal bleeding: color and amount, passage of clots and tissue

c. Abdominal pain/uterine contractions

d. Fundal height (may rise with concealed intrauterine bleeding)

e. FHTs

f. Pain relief


C. Ectopic Pregnancy


An ectopic pregnancy (EP) is defined as the implantation of the fertilized ovum outside the normal uterine cavity. Approximately 95% of EPs are implanted in the fallopian tube, frequently on the maternal right side. If the EP invades the tubal wall too deeply or grows too large, it can rupture the tube. This rupture leads to severe pain, intraperitoneal hemorrhage, and hemorrhagic shock. EP is the leading cause of pregnancy-related maternal death. The remaining EPs implant in the peritoneal cavity, uterine cornu, ovary, or cervix. The incidence of EP has been increasing worldwide, and during the last few decades, the rate has nearly quadrupled in industrialized nations. In the United States, the incidence of EP is approximately 2%; however, complications from EP account for approximately 12% of maternal mortality. Causes of EPs are classified as mechanical, functional, and assisted reproduction. Mechanical obstruction results from narrowing of the fallopian tube, which prevents the normal passage of the ovum. Factors that can lead to mechanical obstruction, which delay the fertilized egg from reaching the uterus, include pelvic inflammatory infection (in PID), salpingitis, fallopian tube surgery, tubal ligation, previous EP, intrauterine device (IUD) use, tumor, or developmental abnormalities of the tube. Functional causes of EP include altered tubal motility from infection or hormonal changes. Reproductive assistance such as the use of ovulation induction agents and in vitro techniques increase the risk of EP. Women of advanced maternal age and women who are African American are also at a higher risk. However, it has been estimated that up to 43% of women presenting with EP have none of these risk factors.




1. Assessment


a. Subjective data collection

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Nov 8, 2016 | Posted by in NURSING | Comments Off on Obstetric and Gynecologic Emergencies

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