Advanced Life Support in Obstetrics
Please refer to your course text for:
Section C: Vaginal Bleeding in Late Pregnancy
Section J: Postpartum Hemorrhage
Also review these two articles from American Family Physician
This article, Common Peripartum Emergencies, is dated but the flow diagrams are still useful for review.
1. Why is knowledge of antepartum and postpartum hemmorrhage important?
2. What are the most common causes of antepartum hemorrhage? How will you diagnose and treat?
3. What are the four T's of postpartum hemorrhage? What will you diagnose and treat?
4. The medication below can be used for postpartum hemorrhage. What is the dosage and how is it administered?
A 24 yo G3P2 woman at 36 wks pregnancy comes in to triage c/o vaginal bleeding. The bleeding began about 1/2 hour ago and is heavier than her usual menstrual period. Her vital signs are normal for pregnancy. The fetal monitor shows the presence of fetal heart activity and cx occurring every 10 minutes. What will you ask? What will you do?
You deliver an 8lb baby from a 35 yo G1P0 woman after a protracted labor. After delivery of the placenta you hear the splashing of blood on the floor. What will you do?
Your G1 now P1 patient comes in for follow-up after her cesarean section. She tells you that she had a lot of bleeding and needed a cesarean hysterectomy. She asks you for a prescription for birth control. What will you say?
Confirmation of Rupture of Membranes
Procedure: Fern and Nitrazine Tests
1. Insert speculum for sample collection, avoid the use of lubricant.
2. Collect vaginal secretion from the posterior vaginal pool with two cotton sterile swabs.
Do not touch the mucus plug in the cervix.
Do not contaminate the specimen with saline/koh.
3. After collection, immediately rub the swab against a glass slide, creating a very thin smear, do not apply a coverslip.
4. Allow slide to dry for 5-10 minutes.
5. Using a microscope, examine the dried smear under 10X power without a cover slip.
6. If present, saline in the amniotic fluid crystallizes to form a fern-like pattern.
The Fern Test should be performed in conjunction with the Nitrazine Test.
1. Tear off a 2-3 cm piece of Nitrazine paper.
2. Apply fluid collected from the vaginal pool directly to the paper.
3. A blue color change is consistent with amniotic fluid pH of 7-7.5. The Nitrazine paper container includes a chart of color change and pH.
Rupture of membranes is confirmed with either:
1) Presence of pooled vaginal fluid on speculum exam
2) Positive Ferning and Nitrazine tests
If the Nitrazine Test and Fern Test are positive, probable membrane rupture has occurred.
Vaginal infection (BV)
ROM> 24 hours.