Obstetrics :Obstetrics EMS Professions Temple College


Pregnancies :Pregnancies Most are uncomplicated Complications can arise from: Eclampsia/Pre-eclampsia Diabetes Hypotension/Hypertension Cardiac disorders Abortion Trauma Placenta abnormalities


Childbirth :Childbirth Involves Labor and Delivery Natural process, often only requiring basic assistance


Childbirth :Childbirth You have at least two patients!


Childbirth :Childbirth Complications can occur Breech/limb presentation Multiple Births Umbilical cord problems Disproportion Excessive bleeding Pulmonary embolism Neonate requiring resuscitation Preterm labor


Female Reproductive System :Female Reproductive System


Female Reproductive System :Female Reproductive System


Anatomy/Physiology :Anatomy/Physiology Ovulation Fertilization Implantation


Anatomy/Physiology :Anatomy/Physiology Placenta Transfer of gases Transport of nutrients Excretion of wastes Hormone production Protection


Anatomy/Physiology :Anatomy/Physiology Umbilical cord Connects placenta to fetus Two arteries One vein Amniotic Sac Membrane surrounding fetus Fluid originates from feral sources 500 - 1000 cc (after 20 weeks) Rupture produces watery discharge


Terminology :Terminology Antepartum - before delivery Postpartum - after delivery Prenatal - occurring before the birth Natal - connected with birth Gravida - number of pregnancies Para - number of pregnancies carried to full term Abortion - number of pregnancies that ended before full term Primigravida - woman who is pregnant for the first time Primipara - woman who has given birth to her first child Multiparous - woman who has given birth multiple times Gestation - period of time for intrauterine fetal development


Fetal Growth Process :Fetal Growth Process End of third month Sex may be distinguished Heart is beating Every structure found at birth is present End of fifth month Fetal heart tones can be detected Fetal movement may be felt by mother End of sixth month May be capable to survive if born prematurely Middle of tenth month Considered to have reached full term Expected date of confinement (EDC)


Ectopic Pregnancy :Ectopic Pregnancy Pathophysiology Outside uterine cavity 95% Fallopian tubes 1 in every 200 pregnancies Most are symptomatic Predisposing factors Tubal infections Previous tubal surgery IUD use previous ectopic pregnancy


Ectopic Pregnancy :Ectopic Pregnancy History Missed period Other signs of early pregnancy Vaginal bleeding 6 -8 weeks after last period Upon rupture, bleeding may be excessive


Ectopic Pregnancy :Ectopic Pregnancy History Lower abdominal pain May be: Sharp or dull Constant or intermittent Diffuse or localized May be referred to shoulder


Ectopic Pregnancy :Ectopic Pregnancy Physical Exam S/S of hypovolemic shock Positive tilt test Tender lower abdomen Palpable mass may be present


Ectopic Pregnancy :Ectopic Pregnancy Abdominal pain or unexplained hypovolemia + woman of child-bearing age = Ectopic pregnancy Until proven otherwise!


Ectopic Pregnancy :Ectopic Pregnancy Management High concentration oxygen IV or IV’s with LR MAST Immediate transport


Abortion :Abortion Termination of pregnancy before fetal viability (20th week)


Abortion :Abortion Induced Therapeutic Criminal Elective


Abortion :Abortion Spontaneous 20 -25% of pregnancies terminate spontaneously Usually due to embryo abnormalities May also result from infection, unfavorable intrauterine environment, cervical incompetence


Abortion :Abortion Spontaneous Threatened Inevitable Complete Incomplete


Abortion :Abortion Threatened Vaginal bleeding, mild or absent contractions, closed cervix 20% of women bleed in early pregnancy 50% go on to abort Any bleeding in early pregnancy is dangerous and abnormal


Abortion :Abortion Inevitable Vaginal bleeding Moderately severe contractions Possible amniotic sac rupture Cervix effacement and dilation Changes are irreversible


Abortion :Abortion Completed Products of conception expelled fetus placenta decidual lining Signs, symptoms Profuse vaginal bleeding Passage of tissue, clots Continuing mild contractions Possible hypotension


Abortion :Abortion Incomplete Products of conception retained Signs, symptoms Profuse bleeding Passage of tissue/clots Severe contractions Hypotension, shock Sepsis


Abortion :Abortion Missed Fetus dies in utero before 20th week Retained at least 2 months afterwards


Abortion :Abortion Missed Signs/Symptoms Continued amenorrhea History of bleeding without cramping Decrease in uterine size Resorption of fluid Calcification of products of conception


Abortion :Abortion History Confirmed or suspected pregnancy Abdominal pain, cramping Bleeding, passage of tissue


Abortion :Abortion Physical Exam Orthostatic vital signs (tilt test) Examine for amount of vaginal bleeding, presence of tissue


Abortion :Abortion Management High concentration oxygen IV or IV’s with LR MAST if indicated Do NOT pack vagina Save any tissue passed Transport


Medical Complications :Medical Complications Diabetes Stable may become unstable Gestational Can not use oral medications Neuromuscular May be aggravated by pregnancy


Medical Complications :Medical Complications Hypertension More susceptible to complications CVA Cardiac Failure Renal Failure May be complicated by preeclampsia or eclampsia Cardiac Disorders Additional stress placed on heart CO increases 30% by week 34


Pregnancy-Induced Hypertension :Pregnancy-Induced Hypertension Two Phases: Pre-eclampsia Eclampsia


Pre-Eclampsia :Pre-Eclampsia In about 7% of pregnancies Between 20th week gestation, first week postpartum Hypertension, albuminuria, edema


Pre-Eclampsia :Pre-Eclampsia Risk Factors First pregnancies Multiple gestations excessive amniotic fluid Diabetes mellitus Renal disease Pre-existing hypertension Family history of pre-eclampsia Poor nutrition


Pre-Eclampsia :Pre-Eclampsia Signs/Symptoms Elevated BP >140/90 or >30mmHg above patient normal Edema of face/hands Especially in morning


Pre-Eclampsia :Pre-Eclampsia Signs/Symptoms Rapid weight gain >3lb/wk - 2nd trimester >1lb/wk - 3rd trimester Decreased urine output


Pre-Eclampsia :Pre-Eclampsia Signs/Symptoms Severe headache Blurred vision Irritability Nausea, vomiting Epigastric pain Pulmonary edema


Eclampsia :Eclampsia Pre-eclampsia + Seizures, Coma


PIH :PIH Management High concentration oxygen IV tko Left lateral recumbent position Quiet environment Reduce excessive light


PIH :PIH Psychological support Avoid lights/sirens in pre-eclampsia Magnesium sulfate 4gm bolus; 1gm/hr infusion Monitor pulse, BP, respiration, patellar reflex Calcium will reverse toxicity


PIH :PIH Assess every pregnant patient for: Increased BP Edema Take all reported seizures in pregnant females seriously


Third Trimester Bleeding :Third Trimester Bleeding 50% due to normal changes in cervix 50% due to placental catastrophe Dangerous if amount greater than normal period


Abruptio Placentae :Abruptio Placentae Premature placental separation from uterus 0.4 - 3.5% of pregnancies Risk Factors Older patients Hypertensives Multigravidas Trauma


Abruptio Placentae :Abruptio Placentae Mild to moderate vaginal bleeding Continuous, knife-like abdominal pain Third trimester pain = Abruption until proven otherwise Rigid tender uterus S/S of hypovolemia Out of proportion to visible bleeding Alteration of contraction pattern


Placenta Previa :Placenta Previa Placental implantation over cervical opening 0.5% of pregnancies Predisposing factors increasing age multiparity previous cesarean sections Can lead to placental insufficiency fetal hypoxia


Placenta Previa :Placenta Previa Painless, bright-red vaginal bleeding Soft, non-tender uterus No contractions S/S of hypovolemia


Third Trimester Bleeding :Third Trimester Bleeding Management 100% Oxygen IV of LR x 2 Left lateral recumbent position MAST, legs only Assess fetal heart tones?


Third Trimester Bleeding :Third Trimester Bleeding Never perform vaginal exam on third trimester patient with vaginal bleeding


Hyperemesis Gravidarum :Hyperemesis Gravidarum Severe nausea, vomiting Leads to starvation, dehydration, acidosis Continued vomiting in pregnancy with loss of weight


Hyperemesis Gravidarum :Hyperemesis Gravidarum Management Replace lost fluids, electrolytes Glucose


Supine Hypotensive Syndrome :Supine Hypotensive Syndrome Uterus compresses inferior vena cava Venous return to heart decreases Decreased venous return leads to decreased cardiac output BP decreases Consider volume depletion


Supine Hypotensive Syndrome :Supine Hypotensive Syndrome Management Place patient on left side to restore venous return Transport all non-laboring patients in late pregnancy on left side


Ruptured Membranes :Ruptured Membranes Vaginal leakage of clear, colorless fluid 84% labor spontaneously in 24 hours, BUT 50% become infected in 12 hours Increased time = Increased infection risk Patient MUST come to hospital


Fever/Dysuria :Fever/Dysuria Major medical emergency Suggests urinary tract or amniotic fluid infection Sepsis or early labor may result Patient MUST come to hospital


Uterine Rupture :Uterine Rupture Common causes: Prolonged labor against obstruction Large fetus Old C-section Multiple pregnancies


Uterine Rupture :Uterine Rupture Signs/Symptoms Sudden, intense, tearing abdominal pain S/S of hypovolemic shock Loss of continuity of uterine mass Possible vaginal bleeding


Uterine Rupture :Uterine Rupture 50 - 75% fetal mortality Management 100% Oxygen IV of LR x 2 Left lateral recumbent position MAST, legs only Rapid transport


Uterine Rupture :Uterine Rupture History of previous C-section Transport immediately unless baby is crowning Determine reason for C-section


Trauma in Pregnancy :Trauma in Pregnancy Minor Trauma Common in the Obstetric Patient Syncopal episodes Diminished coordination Loosening of the joints


Trauma in Pregnancy :Trauma in Pregnancy Major Trauma Susceptible to a life threatening episode increased vascularity may deteriorate suddenly Leading cause of maternal death in pregnancy MVC’s = 50% of perinatal mortality


Trauma in Pregnancy :Trauma in Pregnancy Trauma can lead to Premature separation of the placenta Premature labor Abortion Rupture of the uterus Fetal death Death of mother Separation of the placenta Maternal shock Uterine rupture Fetal head injury


Trauma in Pregnancy :Trauma in Pregnancy Injured woman of child-bearing age, consider pregnancy Priorities EXACTLY same as in any other patient ABC’s first


Trauma in Pregnancy :Trauma in Pregnancy Assessment Vital signs mimic hypovolemia Pulse increases 10-15/minute BP decreases


Trauma in Pregnancy :Trauma in Pregnancy Assessment Blood volume increases up to 45% More blood loss can occur before S/S of hypovolemia appear In hypovolemia, blood is shunted from placenta causing fetal distress


Trauma in Pregnancy :Trauma in Pregnancy Assessment Increased fluid volume needed to treat hypovolemia Penetrating abdominal trauma in second, third trimester frequently involves uterus Greatest danger from uterine injury is hypovolemia


Trauma in Pregnancy :Trauma in Pregnancy Assessment Second, third trimester blunt abdominal trauma may cause: Uterine rupture Placental abruption Premature labor Hemorrhage from uterine vessels


Trauma in Pregnancy :Trauma in Pregnancy Assessment “Loose” joints mimic orthopedic injury Particularly pelvic fracture


Trauma in Pregnancy :Trauma in Pregnancy Management Treat shock early, aggressively Fetus may be distressed when mother is not S/S of shock appear later More volume needed to correct hypovolemia


Trauma in Pregnancy :Trauma in Pregnancy Management Oxygenate aggressively Consider assisting ventilation early Oxygen demand increases 10-20% in last trimester High diaphragm causes decreased compliance, tidal volume


Trauma in Pregnancy :Trauma in Pregnancy Management MAST can be used in late-term pregnancy Inflate legs only Using abdominal compartment reduces blood flow to fetus


Trauma in Pregnancy :Trauma in Pregnancy After first trimester never transport patient flat on back Transport on left side Prop up right side of spine board with blanket, pillows


Trauma in Pregnancy :Trauma in Pregnancy Most common cause of fetal death from trauma is maternal death Keeping mom alive keeps baby alive What’s good for mom is good for baby


Braxton-Hicks Contractions :Braxton-Hicks Contractions Usually occurs in the third trimester Benign phenomenon that simulates labor Contractions are generally painless Walking may help


Preterm labor :Preterm labor Labor that begins prior to 38 weeks gestation Labor results in progressive dilation and effacement of cervix Causes Multiple gestations Intrauterine infections Premature rupture of the membranes Uterine or cervical anatomical abnormalities


Preterm labor :Preterm labor Management Consideration of tocolysis Rest Fluids Sedation Transport for evaluation


Obstetric Patient Assessment :Obstetric Patient Assessment


Obstetric PA :Obstetric PA Recognition of pregnancy Breast tenderness Urinary frequency Amenorrhea Nausea/Vomiting


Obstetric PA :Obstetric PA Obstetric History Gravidity and Parity Gravidity = Number of pregnancies Parity = Number of live births


Obstetric PA :Obstetric PA Obstetric History Last normal menstrual period Estimated delivery date (-3/+7) Previous Ob-Gyn complications Prenatal care (by whom) Previous Cesarean sections


Obstetric PA :Obstetric PA Obstetric Physical Exam Evaluation of Uterine Size 12 to 16 weeks: above symphysis pubis 20 weeks: at umbilicus For each week beyond 20 weeks: 1 cm above umbilicus At term: near xiphoid process


Obstetric PA :Obstetric PA Obstetric Physical Exam Presence of fetal movements ~20th week Presence of fetal heat tones ~20th week Normal: 120 to 160/minute


Obstetric PA :Obstetric PA Presence of Pain Abdominal pain in last trimester suggests abruption until proven otherwise Appendicitis may present with RUQ pain


Obstetric PA :Obstetric PA Presence of vaginal bleeding Always dangerous in first trimester Dangerous in late pregnancy if greater than normal period


Obstetric PA :Obstetric PA General health Diabetes may become unstable Hypoglycemic episodes in early pregnancy Hyperglycemia as pregnancy progresses Hypertension complicated by PIH Cardiovascular disease may worsen


Obstetric PA :Obstetric PA Do tilt test if blood loss is suspected Do NOT tilt patient with obvious shock


Obstetric PA :Obstetric PA Do NOT perform vaginal exams


Obstetric PA :Obstetric PA Warning signs Vaginal bleeding Swelling of face, hands Dimmed, blurred vision Abdominal pain


Obstetric PA :Obstetric PA Warning signs Persistent vomiting Chills, fever Dysuria Fluid escape from vagina