The document discusses topics related to obstetrics including the prenatal period, assessment and management of obstetric patients, complications during pregnancy and delivery, abnormal delivery situations, and maternal complications of labor and delivery. It provides details on the anatomy, physiology, development, and common issues that can arise at each stage of pregnancy, labor, delivery, and the postpartum period. Management guidelines are presented for emergency situations that may be encountered with obstetric patients in the prehospital setting.
2. Topics
The Prenatal Period
General Assessment of the Obstetric
Patient
General Management of the Obstetric
Patient
Complications of Pregnancy
The Puerperium
Abnormal Delivery Situations
Other Delivery Complications
Maternal Complications of Labor and
Delivery
3. The Prenatal Period
The prenatal period is the
time from conception until
delivery of the fetus.
4.
5. Anatomy and Physiology
of the Obstetric Patient
Ovulation—the release of an egg from the ovary.
Placenta—organ of pregnancy
Afterbirth—placenta and membranes that are
expelled from uterus after the birth of a child.
Umbilical cord—structure that connects fetus
and placenta
Amniotic sac—membranes that surround and
protect the developing fetus.
Amniotic fluid—clear watery fluid that surrounds
and protects the developing fetus.
6.
7. Physiologic Changes
of Pregnancy
Reproductive System
Uterus increases in size.
Vascular system.
Formation of mucous plug in cervix.
Estrogen causes vaginal mucosa to thicken.
Breast enlargement.
Respiratory System
Progesterone causes a decrease in airway resistance.
Increase in oxygen consumption.
Increase in tidal volume.
Slight increase in respiratory rate.
8. Physiologic Changes
of Pregnancy
Cardiovascular System
Cardiac output increases.
Blood volume increases.
Supine hypotension.
Gastrointestinal System
Hormone levels.
Peristalsis is slowed.
Urinary System
Urinary frequency is common.
Musculoskeletal System
Loosened pelvic joints.
11. General Assessment of
the Obstetric Patient
Initial Assessment
History—SAMPLE
EDC
Preexisting Medical Conditions
Diabetes, heart disease, hypertension, seizure
Pain
Vaginal Bleeding
Labor
Physical Examination
12. General Management of
the Obstetric Patient
Do not perform an internal vaginal
examination in the field.
Always remember that you are
caring for two patients, the
mother and the fetus.
ABC, monitor for shock.
14. Trauma
Transport all trauma patients
at 20 weeks or more gestation.
Anticipate the development of
shock.
15. Trauma Management
Apply c-collar for cervical stabilization
and immobilize on a long backboard.
Administer high-flow oxygen
concentration.
Initiate two large-bore IVs per protocol.
Place patient tilted to the left to
minimize supine hypotension.
Reassess patient.
Monitor the fetus.
17. Causes of Bleeding
During Pregnancy
Abortion
Ectopic pregnancy
Placenta previa
Abruptio placentae
18. Abortion
Termination of pregnancy before
the 20th week of gestation.
Different classifications.
Signs and symptoms include
cramping, abdominal pain,
backache, and vaginal bleeding.
Treat for shock.
Provide emotional support.
19. Ectopic Pregnancy
Assume that any female of
childbearing age with lower
abdominal pain is experiencing an
ectopic pregnancy.
Ectopic pregnancy is life-
threatening. Transport the patient
immediately.
20. Placenta Previa
Usually
presents with
painless
bleeding.
Never attempt
vaginal exam.
Treat for shock.
Transport
immediately—
treatment is
delivery by
c-section.
21. Abruptio Placentae
Signs and
symptoms vary.
Classified as
partial, severe, or
complete.
Life-threatening.
Treat for shock,
fluid
resuscitation.
Transport left
lateral recumbent
position.
22. Medical Complications
of Pregnancy
Hypertensive Disorders
Supine Hypotensive Syndrome
Gestational Diabetes
23. Hypertensive Disorders
Preeclampsia and Eclampsia
Chronic Hypertension
Chronic Hypertension
Superimposed with Preeclampsia
Transient Hypertension
24. Supine Hypotensive
Syndrome
Treat by placing patient in the left
lateral recumbent position, or
elevate right hip.
Monitor fetal heart tones and
maternal vital signs.
If volume is depleted, initiate an IV
of normal saline.
25. Gestational Diabetes
Consider hypoglycemia when encountering
a pregnant patient with altered mental
status.
Signs include diaphoresis and tachycardia.
If blood glucose is below 60 mg/dl, draw a
red top tube of blood, start IV-NS, give 25
grams of D50. If blood glucose is above
200 mg/dl, draw a red top tube of blood,
administer 1–2 liters NS by IV per protocol.
26. Braxton-Hicks
Contractions
False labor that increases in
intensity and frequency but does
not cause cervical changes
29. Labor
Stage One
(Dilation)
Stage Two
(Expulsion)
Stage Three
(Placental
Stage)
30. Management of a Patient
in Labor
Transport the patient in labor unless
delivery is imminent.
Maternal urge to push or the
presence of crowning indicates
imminent delivery.
Delivery at the scene or in the
ambulance will be necessary.
31.
32. Field Delivery
Set up delivery area. Suction the mouth
Give oxygen to and then the nose.
mother and start Clamp and cut the
IV-NS TKO. cord.
Drape mother with Dry the infant and
toweling from OB kit. keep it warm.
Monitor fetal heart Deliver the
rate. placenta and save
for transport with
As head crowns,
the mother.
apply gentle
pressure.
33. Neonatal Care
Support the infant’s head and
torso, using both hands.
Maintain warmth!
Clear infant’s airway by
suctioning mouth and nose.
Assess the neonate using Apgar
score.
35. Neonatal Resuscitation
If the infant’s respirations are below 30
per minute and tactile stimulation does
not increase rate to normal range,
assist ventilations using bag valve
mask with high-flow oxygen.
If the heart rate is below 80 and does
not respond to ventilations, initiate
chest compressions.
Transport to a facility with neonatal
intensive care capabilities.
37. Breech Presentation
The buttocks or both feet present
first.
If the infant starts to breath with
its face pressed against the
vaginal wall, form a “V” and push
the vaginal wall away from
infant’s face. Continue during
transport.
38. Prolapsed Cord
The umbilical cord precedes the fetal
presenting part.
Elevate the hips, administer oxygen, and
keep warm.
If the umbilical cord is seen in the vagina,
insert two gloved fingers to raise the
fetus off the cord. Do not push cord
back.
Wrap cord in sterile moist towel.
Transport immediately; do not attempt
delivery.
39. Limb Presentation
With limb presentation, place
the mother in knee–chest
position, administer oxygen,
and transport immediately.
Do not attempt delivery.
40. Other Abnormal
Presentations
Whenever an abnormal presentation or
position of the fetus makes normal
delivery impossible, reassure the
mother.
Administer oxygen.
Transport immediately.
Do not attempt field delivery in these
circumstances.
42. Multiple Births
Follow normal guidelines, but
have additional personnel and
equipment.
In twin births, labor starts earlier
and babies are smaller.
Prevent hypothermia.
43. Cephalopelvic
Disproportion
Infant’s head is too big to pass through
pelvis easily.
Causes include oversized fetus,
hydrocephalus, conjoined twins, or fetal
tumors.
If not recognized, can cause uterine rupture.
Usually requires cesarean section.
Give oxygen to mother and start IV.
Rapid transport .
44. Precipitous Delivery
Occurs in less than 3 hours of
labor.
Usually in patients in grand
multipara, fetal trauma, tearing of
cord, or maternal lacerations.
Be ready for rapid delivery , and
attempt to control the head.
Keep the baby warm.
45. Shoulder Dystocia
Infant’s shoulders are larger than
its head.
Turtle sign.
Do not pull on the infant’s head.
If baby does not deliver, transport
the patient immediately.
46. Meconium Staining
Fetus passes feces into the
amniotic fluid.
If meconium is thick, suction the
hypopharynx and trachea using
an endotracheal tube until all
meconium has been cleared from
the airway.
48. Postpartum Hemorrhage
Defined as a loss of more than
500 cc of blood following delivery.
Establish two large-bore IVs of
normal saline.
Treat for shock as necessary.
Follow protocols if applying
antishock trousers.
49. Uterine Rupture
Tearing, or rupture, of the uterus.
Patient complains of severe abdominal
pain and will often be in shock.
Abdomen is often tender and rigid.
Fetal heart tones are absent.
Treat for shock.
Give high-flow oxygen and start two
large-bore IVs of normal saline.
Transport patient rapidly.
50. Uterine Inversion
Uterus turns inside out after delivery
and extends through the cervix.
Blood loss ranges from 800 to 1,800
cc.
Begin fluid resuscitation.
Make one attempt to replace the
uterus. If this fails, cover the uterus
with towels moistened with saline and
transport immediately.
51. Pulmonary Embolism
Presents with sudden severe
dyspnea and sharp chest pain.
Administer high-flow oxygen and
support ventilations as needed.
Establish an IV of normal saline.
Transport immediately,
monitoring the heart, vital signs,
and oxygen saturation.
Notas do Editor
During this time there are significant physiological changes to mother as well as development of fetus.
First 2 weeks of Menstrual cycle dominated by estrogen an which causes endometirum to thicken and become engorged with blood Leutenizing hormone (LH) and follicle stimuklating hormone stimulated ovulation Egg travels down fallopian tube to uterus where it is fertilized and is implanted in the uterus If it is not fertilized menstration takes place 14 days after ovulation Blastocyst – ovum after cellular division
Placenta – develops 3 weeks after fertilization on the site that the blastocyst formed. Exchanges O2 CO2 delivers glucose, potassium, removes urea and creatinine, serves as endocrine gland secreting estrogen and progesterone and other hormones (test question) necessary for fetal survival. Protective barrier except narcs, steroids and antibiotics can cross Umbilical cord - has 2 arteries (return deoxy blood) and 1 vein (tx O2 to fetus) (test question) Amniotic fliud – 500 to 1000cc
Vascular – during pregnancy, the uterus contains 1/6 (16%) mother’s blood volume Mucous plug – protects against infection Estrogen – to prepare for delivery Breast – estrogen to prepare for lactation Respiratory – 20% increase in O2 consumption and 40% increase in tidal volume even though diaphragm is pushing up
CO – 6 to 7 L/min Blood volume – increases by 45%, slight relative anemia (take iron to increase O2 carrying capacity) Urinary – increased renal flow and output, glucosuria normal or a sign of gestational diabetes. Displaced resulting incr potential for rupture Musculoskelatal – waddling gate, postural changes cause back pain
Conception 14 days after first day of LMP Pregnancy 40 weeks after LMP Trimester 13 weeks Fetus have good chance of surviving outside woumb after 28 weeks (test question) Fetus is considered fully developed after 38 weeks (test question)
Fetus does not use resp or GI therefore blood is shunted away When baby take first breath, decreases pulmonary vascular resistance allowing blood to flow. Also blood flow from placenta is stopped
EDC – due date, gravida, para, c-section, past complications, prenatal care Medications and drug allergies Preexisting - Remember, pregnancy can aggravate preexisting problems such as diabetes and heart Pain – onset acute or gradual, regular, radiation Vag bleed – when caring for a patient who is experiencing vaginal bleeding you should, gain info about the color, amount and duration, save any passed clots or tissue for evaluation and assess the amount of bleeding by counting the number of sanitary pads filled. (test question) Labor – does she have the urge to push, has water broken Physical – prolapsed cord, crowning, tilt test (orthostatics)
Left Lateral recumbant position Use analgesics with caution since they can cross placental barrier Transport to facility with appropriate care (ie childrens)
Hypovolemia causes vasoconstriction and reduced blood flow to fetus Therefore, the fetus may be in danger even though the mother is showing no signs or symptoms of shock. (test question) Trauma can cause separation of placenta from uterin wall, uterin rupture, and premature labor.
Increased risk of gallstones. Also appendicitis, cholecystitis. Pain may be different or referred. Could be ectopic life threat
Different classification – spontaneous (miscarriage) or induced S/S – passage of clots, assertain amount of bleeding
Ectopic pregnancy is when the developing fetus implants outside the uterus (test question)
Placent Previa is the abnormal implantation of the placenta on the lower half os the uterine wall, resulting in partial or complete coverage of the cervical opening (test question) Always assume third trimester bleeding is either placenta previa or abruptio placentae Threat of severe hemorrhage
S/S – usually presents with pain, with or without bleeding
Preeclampsia – pregnancy induced hypertension (>140/90) Last 10 weeks to 48 hours postpartum. Vasospams causes fetal hypoxia and fluid overload. c/o headache, visual disturbances, pulmonary edema, pedal edema. Ecplampsia characterized by grand mal seizures. High risk of cerebral hemorrhage, pulmonayr embolism, abruption placentae, renl failure. May administer antihypertensives. Give Mag Sufate 2 to 5 g in 50 ml slow IV push to control seizures
SHS occurs when the gravid uterus compresses the inferior vena cava when the mother lies in the supine position (test question) May complain of dizzyness. Find out if happened before. History of any hemorrhage
GD is when a pregnant woman develops diabetes during pregnancy (test question) During last 20 weeks, placental hormones cause increased resistance to insulin decreased glucose tolerance leading to catabolism (breakdown) of fatty acids and build up of ketones.
Usually irregular, does not cause effacement (thinning of) and dilation of the cervix.
Preterm labor is labor prior to 38 weeks. Frequently requires medical intervention Some causes are: In many cases, labor is stopped to allow the fetus more time to grow Fluid bolus of 1 liter may stop labor. Stimulates ADH release stopping Oxytocin releas
Stage 1 – effacement begins several days before dilates to 10 cm (8 to 10 hours) early contractions mild, 15 to 20 sec long, 10 to 20 min apart late contractions, 2 to 3 min apart, 60 sec long Stage 2 – contractions every 2 min 60 to 75 sec long, pain in lower back urge to push, membranes rupture if they haven’t already Stage 3 – 5 to 20 min, do not delay transport
Number of previous pregnancies, and the length of labor before Urge to push Crowning Transport immediately if membranes ruptured >24 hours ago, fetus at risk for infection, abnormal presentation, fetal distress
Place mother in semi fowlers with knees bent Fetal heart rate should not drop below 90 bpm As the head delivers Support head as it rotates to side, suction mouth first because because suctioning nose may stimulate gasp (obligate nasal breathers) (break sac if necessary) gently slide fingers to ensure cord is not wrapped around neck (if too tight to loosen, clamp and cut) check for meconium Guide head down to deliver top shoulder, then up to deliver top shoulder, be aware remainder of body comes quick Keep baby at level of vagina clamp cord 10 cm (4 in) from infant and cut Dry, Warm, Position, Suction, Stimulate. Place baby on mother and record time of birth Do not pull on umbilical cord to deliver placenta, massage uterus to stop bleeding Pitocin(Oxytocin) should only be used after delivery of placenta Cover perineum with bandage if torn
Neonates are slippery Cold infants become distressed, replaced wet towels with dry Suctioning will stimulate baby to breath, Always suction the mouth first so there is nothing to aspirate if the infant gasps when its nose is suctioned (test question) can flick foot or rub back Resp – 30 to 60 bpm HR – 100 to 180
Assigned at 1 and 5 minutes after birth Score 7 to 10 routine care 4 to 6 moderately depressed require O2 0 to 3 severly depressed and require ventilatory and circulatory assistance
Vertex position, 4% births Increased risk of trauma to mother and baby And prolapsed cord, cord compression, infant anoxia Associated with preterm, multiples, placenta previa Should be c section, however if imminent delivery may need to turn baby to deliver shoulders
Just as in prolapsed cord
Occiput posterior position – face is usually posterior but not here
May have 1 or 2 placentas for twins
Occurs in diabetics and obese mothers Turtle sign – shoulder trapped between symphysis pubis and sacrum
Indicative of fetal hypoxia Risk of aspiration an morbidity Amniotic fluid usually straw colored, meconium staining like Pea soup May occur in prolonged labor, breech delivery
Measure blood loss in pads Fundal message pitocin
Can be caused by labor or blunt trauma
Rare Can be caused by pulling on umbilical cod to express placenta
Blood clot Most common cause of maternal death s/s tachycardia, tachypnea, JVD, impending doom