Tag Archives: ob/gyn

4 T’s of life threatening post-partum hemorrhage

20 Oct
via the crashingpatient’s compilaton on some critical L&D emergencies:
 
Differential — 4 T’s:
 
TONE – uterine atony
TRAUMA – genital tract trauma
TISSUE – retained placental tissue
THROMBIN – coagulopathies
 
 
Treatment Options:
  • Empty the uterus: deliver fetus/placenta/retained products
  • Oxytocin / ergometrine / prostaglandin
  • Massage & bimanual compression of uterus
  • Repair genital tract injury
  • Uterine packing, blakemore or Rusch balloon
  • Compression of aorta
  • Surgical or IR: internal iliac or uterine artery ligation, hysterectomy, arterial embolisation
 
 
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resuscitation in pregnancy

27 Feb

via a nice recent post at emDocs.  Click through for the whole read, but if you only have 30 seconds to spare…

QUICK PEARLS:

put your IV above the diaphragm (uterus compresses IVC)

 

remove fetal monitoring equipment prior to defib

 

if you need to RSI, etomidate + succinylcholine is safe

  • (Epocrates lists both as pregnancy “C”, though if you need an airway, benefit probably outweighs risk)
  • “Etomidate will cross the placental barrier, but causes less fetal respiratory suppression than other medications, and succinylcholine does not cross the placental membrane.”

 

peri-mortem c-section: by 4 MINUTES INTO CODE

 

IF YOU HAVE ANOTHER 30 SECONDS:

extra-thinking mnemonic for pregnant code: BEAU-CHOPS

B=Bleeding/DIC

E=Emboli: coronary, pulmonary, amniotic fluid

A=Anesthetic Complications (aspiration, local anesthetic toxicity)

U=Uterine Atony

C=Cardiac Disease i.e. cardiomyopathy, aortic dissection

H=Hypertensive disease i.e. preeclampsia-eclampsia

O=Other-think about the Hs and Ts

P=Placental abruption, previa

S=Sepsis

References: emDocs post, peri-mortem c-section refresher; picture

can’t find a Word catheter?

5 Dec

my current workplace has a decent stash of Word catheter’s, having worked in places where they are in short supply, it’s nice to have a few tricks up your sleeve if you need to improvise, such as this idea from an old ALiEM post:

 

basically, grab a rubber tube threaded with suture.

 

pull it through the bartholin abscess like a loop drainage (click through for a refresher + video)

 

Not rocket science.  Add it to the mental toolbox.

 

References: ALiEM post (& picture); loop abscess post; loop picture

Breech delivery

22 May

In the ED, assisted breech delivery methods should be used.

Total breech extraction only used in case of breech second twin delivery. Otherwise, cervix may not tolerate procedure.

Assisted breech delivery:

If available, clearly get anesthesia/pediatrics/OBGYN into ED.

Episiotomy may assist with delivery. (less popular nowadays)

Pinard maneuver:

  • Wait until baby umbilicus at level of perineum.
  • Then place pressure on popliteal area of fetal legs to flex and help clear vagina.
  • Mother exerts pressure while physician applies gentle downward and out pressure to baby until see scapula and axilla.
  • Wrap dry towel around hips, continue traction with assistant applying fundal pressure to keep fetal head flexed.
  • Rotate 90 degrees and apply pressure to inner aspect of arm to sweep out.
  • Then rotate 180 degrees and same to other arm.
  • Then rotate to baby with back anterior.
  • Then keep head flexed with physician applying upward pressure to maxillary processes of baby with assistant applying fundal pressure, and gently deliver head.

 

Submitted by J. Rothstein.

 

References: medscape article; picture

foley as improvised Word catheter for Bartholin’s abscess

10 Jan

can’t find a Word catheter to keep a Bartholin’s gland abscess open after an I&D?  try this nice MacGuyver move from a recent ACEP News article:

 

WHY DOES THIS MATTER?

“Bartholin glands normally secrete lubrication into the vaginal vestibule via small ducts, but if they become occluded, cyst and abscess formation may follow.”

“…likely to recur if we do not ensure that a new duct can form to allow the gland to drain normally.”

one common way is to leave a Word catheter in place for 2-4 weeks

 

WHAT WOULD MACGUYVER (or Dr. Fisher, article author) DO?

YOU NEED:

  • peds foley catheter (8 or 10 French)
  • hemostats
  • scissors
  • cyanoacrylate tissue adhesive (e.g. Dermabond)
  • PPD or insulin syringe
  • usual I&D kit

 

MAKE IT WORK:

  • I&D as usual
  • insert deflated foley into abscess cavity
  • inflate with 3-4mL saline/water
  • clamp foley with hemostat a few cm distal to baloon
  • cut catheter distal to clamp
  • draw up some Dermabond into insulin/PPD syringe
  • inject adhesive directly into balloon channel (smaller, non-central, not-for-urine) 
  • may need more than one round of adhesive
  • give it a few minutes, then remove hemostat
  • balloon can be deflated after 2-4 weeks by cutting the catheter again (include discharge instructions if the follow-up doc may be unfamiliar with these)

 

Sounds cool.  Nice to have options.

 

References: acepnews article; word pic; foley pic

 

 

Perimortem C-section

25 Oct

great post from this year at St. Emlyn’s blog:

 

Click through for the entire post, worth a quick read, (and old post has a great video review, too) but here are some highlights:

 

You do NOT have time to open a textbook, phone a friend, wait for peds/OB (though you should stat page ’em), etc.  

 

ALLOCATE:

  • someone to run the adult code,
  • someone to resus the baby,
  • someone (you) to do the peri-mortem C-sxn

 

in a pinch: the “Thoracotomy tray has retractors, scissors and clamps which together with a scalpel is all that you will need.”

 

“What feels slow for you is probably fine. Do it right first time without removing anyone’s fingers.”

 

midline vertical incision from pubis to umbilicus”

“If the placenta is in the way, you will just have to cut through it.”

Deliver the head, body should follow. Cut the cord, hand the baby off. Deliver placenta.

 

“Use the greatest simulator known to mankind – the Human Brain”

 

Be prepared.

 

References: St. Emlyn post; old video post; picture

 

Trauma in the pregnant patient

18 Jun

 

Submitted by F. DiFranco.