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Obstetrics

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					         Obstetrics

Eileen M. Humphreys PA-C, EMT-I
           Anatomy Review
• Developing baby -fetus
• Fetus grows in the uterus or womb
• Uterus is a muscular organ which contracts
  during labor to help push out the baby
• Cervix is the neck of the uterus and widens
  to 10cm to allow the baby to pass through
  the vagina
• Vagina is also called the birth canal
          Anatomy Review
• Placenta is an inner lining of the uterus
• This is where oxygen and nutrient exchange
  takes place
• Attached to the baby by the umbilical cord
• Generally weighs a pound
• Expelled after the baby is born
           Anatomy Review
• Mother and fetal blood do not mix in the
  umbilical cord
• Baby’s blood flows from the umbilical cord
  to the placenta where it picks up oxygen
  and nutrients then returns back through the
  umbilical cord to the baby
           Anatomy Review
• Umbilical cord has 2 arteries and 1 vein
• Vein carries nutrients and oxygen to the
  fetus
• Arteries carry waste and deoxygenated
  blood back to the placenta
           Anatomy Review
• Amniotic sac is a thin membranous bag
  which contains 500-1000ml of fluid
• Fetus floats in the amniotic sac or bag of
  waters
• This fluid cushions the fetus against minor
  injury and helps maintain a constant
  temperature
           Anatomy Review
• During labor this sac breaks expelling fluid
• This fluid lubricates the birth canal and
  removes any bacteria
• During delivery part of the sac is forced
  ahead of the infant which serves as a wedge
  to help dilate the cervix
                 Obstetrics
• Green or yellowish-brown amniotic fluid is
  an indicator of maternal or fetal distress and
  is called meconium staining
• Suction mouth and nose quickly to prevent
  aspiration
          Anatomy Review
• Perineum-area between the vagina and anus
• Can be torn during delivery
               Obstetrics
• Increases seen in pregnancy:
           • Heart rate (10-15bpm)
              • Respiratory rate
          • Blood volume (plasma)
            • Oxygen requirements
              Obstetrics
• Decreases seen in pregnancy:
• Blood pressure (10-15mmHg) by the end of
               the 1st trimester
                Obstetrics
Pregnancy is a hypervolemic state-increase in
  plasma and red blood cell mass
This is important to understand as the pt may
  lose 30-35% of circulating blood volume
  before developing hypotension
A pregnant female with hypotension requires
  aggressive fluid replacement
                Obstetrics
• Blood flow is diverted away from the fetus
  in episodes of maternal hypotension
  because the uterus blood vessels do not
  dilate
• This causes fetal bradycardia and results in
  a decrease of oxygen
• Even brief episodes of hypotension may
  cause fetal death
               Obstetrics
• When assessing trauma in pregnancy
  remember that most abdominal organs are
  displaced upward
                Obstetrics
• Pregnancies usually last 280 days (approx 9
  months) and are divided into trimesters
• 1st trimester-fetus is being formed
• 2nd trimester-rapid growth
• 3rd trimester-finer details are finished
                    Labor
• 3 stages
• 1st stage-starts with regular contractions
  and ends when the cervix is completely
  dilated
• 2nd stage-starts when the baby enters the
  birth canal and ends with the birth
• 3rd stage-starts after the birth and ends after
  the placenta or afterbirth is expelled
           1 st   stage of labor
• Usually lasts 16 hrs for 1st time mothers
• Aching sensation in the small of the back
• Changes to mild cramps in the low
  abdomen occurring in regular intervals
• Interval between cramps shortens and
  cramp time lengthens
• Cramps intensify
                 1 st   stage
• May see the mucus plug during this stage
• Also called the dilation stage
• Ends when contractions are 3-4 minutes
  apart and lasting 60 seconds
                   Labor
• Time the contractions or duration from the
  beginning of contraction to relaxation of the
  uterus
• Contraction interval is the time from the
  beginning of one contraction to the
  beginning of the next contraction
           2 nd   stage of labor
• Called the expulsion stage
• Infant moves down the birth canal
• Contractions are usually 2-3 minutes apart
  lasting 45-90 seconds
• Mother feels a pressure in the rectum (urge
  to have a bowel movement)-delivery is
  imminent
          2 nd   stage of labor
• Perineum bulges outward
• Crowning is noted
                  Labor
• Crowning occurs when the presenting part
  of the baby first bulges from the vaginal
  opening-hopefully the head
• Normal birth is head first-a cephalic
  presentation
• Breech presentation is when any other part
  besides the head is seen first usually
  legs/arms
           3 rd   stage of labor
• Placental stage
• Placenta separates from the uterine wall
• Usually occurs between 10-20 minutes after
  birth
 Supine Hypotensive Syndrome
• Occurs when the baby and uterus compress
  the inferior Vena Cava as the mother lies
  supine
• Causes a reduced return of blood to the
  heart
• Causes dizziness, decreased blood pressure
 Supine Hypotensive Syndrome
• Mother’s body tries to compensate by
  rerouting blood flow away from the fetus to
  the mother’s heart
• May cause fetal distress
• Mimics shock
• To treat place the mother and ALL 3rd
  trimester pregnancies on their left side
               Obstetrics
• Transport any expecting mother unless you
  expect delivery within a few minutes
• Determined by the focused history and
  physical exam
                  Obstetrics
               • Questions to ask
•   Name, age, expected due date
•   What number pregnancy is this
•   How long has she been having labor pains
•   Has her water broken
•   Does she feel like she needs to have a bowel
    movement
               Obstetrics
                 • Examination
• Check for crowning by looking at the
  vaginal opening
• Feel for uterine contractions by placing
  your hand on her abdomen above the navel
• Take vital signs
                  Obstetrics
                • When to transport
•   Pregnancy with no straining or crowning
•   If delivery is suspected during transport
    then stop the ambulance
•   Reassess the patient
•   If crowning is noted then prepare for
    delivery
                  Obstetrics
           • When to wait for delivery
•   Crowning has occurred
•   Contractions are closer than 2 minutes apart
•   Contractions are intense and last 30-90
    seconds
•   Urge to have a bowel movement or push
•   Abdomen is very hard
                Obstetrics
• If delivery is suspected during transport
  then stop the ambulance
• Reassess the patient
• If crowning is noted then prepare for
  delivery
                   Delivery
•   Give privacy
•   You need gloves, mask, gowns, and caps
•   Place mother on bed, floor, or stretcher
•   Elevate the buttocks with blankets or pillow
•   Draw legs up to chest with knees flexed out
•   Place sterile towels over each knee and over
    the abdomen as well as under the buttocks
                   Delivery
•   You are there to assist the mother
•   It’s a natural process
•   Talk to the mother, reassure, and calm her
•   Time the contractions
•   Look for the head at the vaginal opening-
    cephalic presentation is normal
                Delivery
• Monitor mother’s vital signs and be
  prepared to suction
• When the baby’s head is seen place your
  hands at the vaginal opening
• As the baby delivers place one hand below
  his head for support and control
• Spread your fingers apart and try to avoid
  the soft spots
                 Delivery
• Support the baby’s head and control it to
  avoid an explosive delivery
• Use your other hand to pull down on the
  perineum to help widen the opening to
  avoid tearing
                 Delivery
• If the amniotic sac has not broken by the
  time the head has delivered then puncture
  the membrane with your finger
• Amniotic fluid should be clear
• Green or yellowish-brown amniotic fluid is
  an indicator of maternal or fetal distress and
  is called meconium staining
                 Delivery
• As soon as the head delivers check to see if
  the cord is wrapped around the neck
• Mother should NOT be pushing at this point
• If the cord is wrapped around the neck then
  loosen and unwrap the cord from the neck if
  possible
• If not then you will have to clamp and cut
  the cord
                Delivery
• Support the head
• Wipe the mouth and nose with sterile gauze
• Suction the mouth 2 or 3 times then suction
  the nose
• Insert the syringe 1 –1.5 inches into the
  mouth
                Delivery
• Help deliver the upper shoulder by gently
  guiding the baby’s head downward
• After the upper shoulder has delivered then
  guide the head upwards to help the lower
  shoulder deliver
• Babies are slippery so make sure you have a
  good firm hold on them at all times
                 Delivery
• Avoid holding the newborn under the
  armpits as this may cause brachial plexus
  injuries
                 Delivery
• After delivery place the baby on it’s side
  with the head slightly lower then the body
  to help with drainage but keep it level with
  the vagina until the cord stops pulsating
• Infant will still have the vernix (cheesy
  covering) on-do not try to wipe off
                Delivery
• Re-suction the mouth and nose
• Wrap the baby to keep it warm
• Note the time of birth
         The Umbilical Cord
• Before the cord is cut make sure it is not
  pulsating anymore
• Use sterile clamps if available
• Place one clamp 6 inches from the baby
• Second clamp is placed 3 inches from the
  1st clamp
         The Umbilical Cord
• Cut the cord between the clamps
• Watch your eyes and mouth because blood
  is in the cord and it will spurt out
• Monitor the cut ends of the cord as even
  small amounts of blood loss may cause
  major problems
• If bleeding is seen then place another clamp
  or hold direct pressure
       Assessing the Newborn
• General evaluation consists of
               • Appearance
                   • Pulse
                 • Grimace
                 • Activity
               • Respiration
         Assessing the Newborn
                    • APGAR
•   At 1 and 5 minutes after birth
•   Reveals trends in the infant’s condition
•   Max points-10
•   2 points per assessment category
      Assessing the Newborn
• 0-3 points-severely depressed, needs
  aggressive intervention
• 4-6 points-moderately depressed-provide
  stimulation & O2
• 7-10 points-infant should be active
       Assessing the Newborn
• Newborns should have
            • heart rate above 100
              • breathing easily
               • crying loudly
          • moving all extremities
  • have blue coloring only at the hands and
                  feet if at all
   Resuscitation of the newborn
• Clear the airway by suctioning the mouth
  then nose (if the nose is cleared before the
  mouth the baby may suck in fluids from the
  mouth into the lungs)
• Keep the baby on it’s side and suction again
• Assess breathing-newborns should start
  breathing within 30 seconds of birth
   Resuscitation of the newborn
• If not, then gently rub the back or flick your
  fingers against sole of his foot
• If breathing is slow, shallow, or absent
  PROVIDE artificial ventilations at 40 to 60
  times per minute
• Remember use only small puffs of air or use
  an infant BVM
• Reassess after 30 seconds
   Resuscitation of the newborn
• Assess heart rate
• If less than 100 per minute but more than 60
  begin PPV with O2 for 30 to 60 seconds
• Continue with PPV and O2 until rate rises
  above 100 per minute
   Resuscitation of the newborn
• If heart rate is less than 80 but greater than
  60 start aggressive PPV with O2
• If rate does not increase above 80 then start
  chest compressions at rate of 120/minute
• If at any time the heart rate falls below 60
  start chest compressions
   Resuscitation of the newborn
• Chest compression depth is 1/2 inches
• Compression rate is 120/minute
• Wrap hands around infant’s torso and place
  thumbs on the lower 3rd of the sternum
                Newborns
• If respirations are adequate but the baby is
  cyanotic in the face, or torso provide O2 at
  15 lpm using a blow by method
             General Care
• Keep the baby very warm
• Wrap the head since most heat loss occurs
  here
• Allow the mother to hold the baby
                  Obstetrics
                • Placenta delivery
•   3rd stage of labor is delivery of the placenta
•   Starts with return of labor pain
•   Cord will begin to lengthen
•   Do not pull on the cord
•   Placenta should deliver within 10 minutes
                Obstetrics
• If the placenta does not deliver within 20
  minutes then transport
• Save everything and give to the hospital
                Obstetrics
• Controlling vaginal bleeding after birth
• Around 500cc’s blood loss is normal
• Place sanitary napkin over the vaginal
  opening
• Do not place anything inside the vagina
• Massage the uterus which will help to
  constrict blood vessels and control bleeding
               Obstetrics
• Skin between the vagina and rectum is
  called the perineum and may tear during
  childbirth
• Bleeding may also occur here so place a
  sanitary napkin and apply light direct
  pressure
     Childbirth Complications
• Breech presentation-buttock or leg first
  delivery
• RAPID transport with high flow O2
• Never attempt delivery by pulling on the
  legs
• Place mother in head down position with
  the pelvis elevated
• If baby delivers care and treat as normal
       Childbirth Complications
            • Prolapsed umbilical cord
•   Occurs when the umbilical cord presents
    first
•   Cord is squeezed between the vaginal wall
    and head of the baby
•   Cords gets pinched and oxygen supply may
    be totally interrupted
•   Causes fetal distress and death
     Childbirth Complications
• Position the mother head down with
  buttocks raised and give high flow O2
• Check cord for pulses and wrap the exposed
  cord to keep warm
• Insert several fingers of your hand into the
  vagina so you can gently push up the baby’s
  head to keep pressure off the cord
• Maintain position until you arrive at the
  hospital
       Childbirth Complications
               • Limb presentation
•   Usually a foot or arm
•   Usually will also have a prolapsed cord
•   Care for the cord as above
•   Transport ASAP
•   Place mother head down with pelvis up
•   High flow O2
•   Do not pull or push on the limb
            Multiple births
• Mother may not know she is carrying twins
• Same care except clamp and cut the cord of
  the 1st baby before the second baby is born
• Label babies as A and B
• NOTE time of each birth
• May share a placenta or each have one
             Multiple births
            • Signs of another baby:
• Abdomen is still very large after the 1st
  infant is born
• Uterine contractions continue to be strong
  after delivery of the 1st infant
• 1st infant’s size is small in proportion to the
  size of the mother’s abdomen
             Multiple births
• Usually the second infant will be in a
  breech presentation
            Premature birth
• Born before 38th week or an infant who
  weighs less than 5 1/2 lbs.
• Infant is smaller, thinner, more reddened
  skin color
• More susceptible to hypothermia and
  respiratory distress
• May require more vigorous care
                  Obstetrics
          • Birth with meconium staining
•   Greenish or yellowish brown fluid
•   If present then suction the mouth then nose
    before assuring an open airway
•   Also usually seen in breech births
•   Aspirating meconium can cause neonatal
    pneumonia
       Obstetric Emergencies
             • Prebirth bleeding
• 2 types:
               • Placenta previa
              • Abruptio placenta
• Both occur in the 3rd trimester
• Both are life-threatening
       Obstetric Emergencies
• Placenta previa-placenta is formed in an
  abnormal location usually close to the
  cervix opening or over the opening
• May tear when fetus moves
• May tear when cervix dilates
• Painless excessive bleeding occurs during
  birth
            Placenta Previa
• Uterus is soft without tenderness to
  palpation
• present fetal heart tones and movement
       Obstetric Emergencies
• Abruptio placenta occurs when the placenta
  separates from the uterine wall prematurely
• Very painful
• Massive or little bleeding-may bleed behind
  the placenta
         Abruptio Placenta
• Abdomen is rigid with tenderness to
  palpation
• Fetal heart tones are absent
• Shock symptoms with/without major blood
  loss visible
       Obstetric Emergencies
• Both require rapid transport with high flow
  O2
            Ectopic pregnancy
•   Leading cause of death in the 1st trimester
•   Implantation anywhere outside of the uterus
•   Usually seen very early in pregnancies
•   Usually results in abortion
•   ANY WOMAN OF CHILDBEARING
    AGE WITH ABDOMINAL PAIN is
    considered to have an ectopic pregnancy
    until proven otherwise
            Ectopic pregnancy
              • Signs and symptoms
•   acute abdominal pain
•   vaginal bleeding
•   Shock
•   Sudden sharp knife-like pain on one side
            Ectopic pregnancy
•   Patient care for ectopic pregnancies
•   Position patient for shock
•   High flow O2
•   Keep NPO
                Toxemia
• Preeclampsia-high blood pressure, swelling
  of the extremities, headaches, and visual
  disturbances
• Eclampsia-2nd stage of toxemia. Seizures
  occur
                 Toxemia
• Seizures can be life-threatening to the fetus
  and mother
• Placenta may rupture or tear during seizures
• PPV with high flow O2 during seizures
           Ruptured Uterus
• Uterine wall is very thin and may tear
  spontaneously or traumatically
• Fetus is expelled into the abdominal cavity
• Fetal mortality is 50%
• Maternal mortality is 5-20%
• Immediate surgery needed
                Obstetrics
                   • Abortion
• Occurs when the fetus is expelled before it
  can live on it’s own-usually before the 28th
  week
                    • 2 types
• Spontaneous abortion-miscarriage
• Induced abortion results from deliberate
  actions to stop the pregnancy
                Obstetrics
            • Signs and symptoms
• cramping abdominal pains
• moderate to severe bleeding
• noticeable discharge of tissue and blood
  from the vagina
                  Obstetrics
                  • Patient care
•   Vitals
•   High flow O2
•   Place sanitary napkin at vaginal opening
•   Transport
•   Save all tissues that are expelled
•   Provide emotional support
•   Always use the term miscarriage
                Obstetrics
                   • Trauma
• Usually caused by MVA or abuse
• In assessing the pregnant patient remember
  the pulse is normally 10-15 beats faster,
  respirations are also increased
• More blood loss seen before patient exhibits
  shock signs
                  Obstetrics
                   • Patient care
•   Be quick to provide CPR or rescue breaths
    as needed to allow fetus good chance at
    survival
•   High flow O2
•   Be ready to suction
•   Transport on LBB tilted to the left to keep
    pressure off the Vena Cava
    Gynecological emergencies
              • Sexual assault
• Scene safety
• Provide open airway
• Avoid disturbing or moving any evidence
• Do not allow the patient to bathe, wash, or
  urinate
• Always have another partner preferably the
  same sex as the patient with you ALWAYS
• DOCUMENT