Obstetrics

EMS Professions Temple College

Pregnancies

Most are uncomplicated Complications can arise from:

Eclampsia/Pre-eclampsia Diabetes Hypotension/Hypertension Cardiac disorders Abortion Trauma Placenta abnormalities

Childbirth

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

Childbirth

You have at least two patients!

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

Anatomy/Physiology

Ovulation Fertilization Implantation

Anatomy/Physiology

Placenta
Transfer of gases Transport of nutrients Excretion of wastes Hormone production Protection

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

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

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

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

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

Ectopic Pregnancy

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

Ectopic Pregnancy

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

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

Ectopic Pregnancy

Management
High concentration oxygen IV or IVs with LR MAST Immediate transport

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

Abortion

Induced
Therapeutic Criminal Elective

Abortion

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

Abortion

Spontaneous
Threatened Inevitable Complete Incomplete

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

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

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

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

Abortion

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

Abortion

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

Abortion

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

Abortion

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

Abortion

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

Medical Complications

Diabetes
Stable may become unstable Gestational Can not use oral medications

Neuromuscular
May be aggravated by pregnancy

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

Two Phases:
Pre-eclampsia Eclampsia

Pre-Eclampsia

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

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

Signs/Symptoms
Elevated BP
>140/90 or >30mmHg above patient normal

Edema of face/hands
Especially in morning

Pre-Eclampsia

Signs/Symptoms
Rapid weight gain
>3lb/wk - 2nd trimester >1lb/wk - 3rd trimester

Decreased urine output

Pre-Eclampsia

Signs/Symptoms
Severe headache Blurred vision Irritability Nausea, vomiting Epigastric pain Pulmonary edema

Eclampsia
Pre-eclampsia + Seizures, Coma

PIH

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

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

Assess every pregnant patient for:

Increased BP Edema

Take all reported seizures in pregnant females seriously

Third Trimester Bleeding

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

Abruptio Placentae

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

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

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

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

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

Never perform vaginal exam on third trimester patient with vaginal bleeding

Hyperemesis Gravidarum

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

Hyperemesis Gravidarum

Management
Replace lost fluids, electrolytes Glucose

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

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

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

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

Uterine Rupture

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

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

50 - 75% fetal mortality Management

100% Oxygen IV of LR x 2 Left lateral recumbent position MAST, legs only Rapid transport

Uterine Rupture

History of previous C-section

Transport immediately unless baby is crowning Determine reason for C-section

Trauma in Pregnancy

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

Trauma in Pregnancy

Major Trauma
Susceptible to a life threatening episode
increased vascularity may deteriorate suddenly

Leading cause of maternal death in pregnancy MVCs = 50% of perinatal mortality

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

Injured woman of child-bearing age, consider pregnancy Priorities EXACTLY same as in any other patient ABCs first

Trauma in Pregnancy

Assessment
Vital signs mimic hypovolemia Pulse increases 10-15/minute BP decreases

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

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

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

Trauma in Pregnancy

Assessment
Loose joints mimic orthopedic injury Particularly pelvic fracture

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

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

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

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

Most common cause of fetal death from trauma is maternal death Keeping mom alive keeps baby alive Whats good for mom is good for baby

Braxton-Hicks Contractions

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

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

Management
Consideration of tocolysis
Rest Fluids Sedation

Transport for evaluation

Obstetric Patient Assessment

Obstetric PA

Recognition of pregnancy
Breast tenderness Urinary frequency Amenorrhea Nausea/Vomiting

Obstetric PA

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

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 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 Physical Exam

Presence of fetal movements
~20th week

Presence of fetal heat tones

~20th week Normal: 120 to 160/minute

Obstetric PA

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

Obstetric PA

Presence of vaginal bleeding

Always dangerous in first trimester Dangerous in late pregnancy if greater than normal period

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

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

Obstetric PA

Do NOT perform vaginal exams

Obstetric PA

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

Obstetric PA

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