ObstetricsObstetrics

TopicsTopics

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

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

The Prenatal The Prenatal PeriodPeriod

The prenatal period is The prenatal period is the time from the time from

conception until conception until delivery of the fetus.delivery of the fetus.

Anatomy and Anatomy and Physiology of the Physiology of the Obstetric PatientObstetric 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.

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.

Physiologic Changes Physiologic Changes of Pregnancyof 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.

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.

Physiologic Changes Physiologic Changes of Pregnancyof 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.

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.

Fetal

Development

Fetal

Development

Fetal CirculationFetal Circulation

General Assessment General Assessment of of

the Obstetric Patientthe Obstetric Patient Initial Assessment History—SAMPLE

EDC Preexisting Medical Conditions

Diabetes, heart disease, hypertension, seizure

Pain Vaginal Bleeding Labor

Physical Examination

Initial Assessment History—SAMPLE

EDC Preexisting Medical Conditions

Diabetes, heart disease, hypertension, seizure

Pain Vaginal Bleeding Labor

Physical Examination

General General Management of Management of

the Obstetric Patientthe 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.

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.

Complications of Complications of PregnancyPregnancy

Trauma Trauma Transport all trauma Transport all trauma

patients at 20 weeks or patients at 20 weeks or more gestation. more gestation. Anticipate the Anticipate the

development of shock.development of shock.

Trauma Trauma ManagementManagement 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.

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.

Medical Conditions Medical Conditions Any pregnant patient Any pregnant patient with abdominal pain with abdominal pain

should be evaluated by should be evaluated by a physician.a physician.

Causes of Bleeding Causes of Bleeding During PregnancyDuring Pregnancy

Abortion Ectopic pregnancy Placenta previa Abruptio placentae

Abortion Ectopic pregnancy Placenta previa Abruptio placentae

AbortionAbortion

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.

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.

Ectopic PregnancyEctopic 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.

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.

Placenta PreviaPlacenta Previa Usually

presents with painless bleeding.

Never attempt vaginal exam.

Treat for shock. Transport

immediately—treatment is delivery by c-section.

Usually presents with painless bleeding.

Never attempt vaginal exam.

Treat for shock. Transport

immediately—treatment is delivery by c-section.

Abruptio PlacentaeAbruptio Placentae Signs and

symptoms vary. Classified as

partial, severe, or complete.

Life-threatening. Treat for shock,

fluid resuscitation.

Transport left lateral recumbent position.

Signs and symptoms vary.

Classified as partial, severe, or complete.

Life-threatening. Treat for shock,

fluid resuscitation.

Transport left lateral recumbent position.

Medical Medical Complications Complications of Pregnancyof Pregnancy

Hypertensive Disorders Supine Hypotensive Syndrome Gestational Diabetes

Hypertensive Disorders Supine Hypotensive Syndrome Gestational Diabetes

Hypertensive Hypertensive DisordersDisorders Preeclampsia and Eclampsia

Chronic Hypertension Chronic Hypertension

Superimposed with Preeclampsia Transient Hypertension

Preeclampsia and Eclampsia Chronic Hypertension Chronic Hypertension

Superimposed with Preeclampsia Transient Hypertension

Supine Hypotensive Supine Hypotensive SyndromeSyndrome

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.

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.

Gestational Gestational DiabetesDiabetes 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.

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.

Braxton-Hicks Braxton-Hicks Contractions Contractions False labor that False labor that

increases in intensity increases in intensity and frequency but does and frequency but does

not cause cervical not cause cervical changeschanges

Preterm LaborPreterm Labor Maternal Factors

Cardiovascular disease, renal disease, diabetes, uterine and cervical abnormalities, maternal infection, trauma, contributory factors

Placental Factors Placenta previa Abruptio placentae

Fetal Factors Multiple gestation Excessive amniotic fluid Fetal infection

Maternal Factors Cardiovascular disease, renal disease, diabetes,

uterine and cervical abnormalities, maternal infection, trauma, contributory factors

Placental Factors Placenta previa Abruptio placentae

Fetal Factors Multiple gestation Excessive amniotic fluid Fetal infection

The Puerperium The Puerperium Puerperium—the time Puerperium—the time period surrounding the period surrounding the

birth of birth of the fetusthe fetus

LaborLabor Stage One

(Dilation) Stage Two

(Expulsion) Stage

Three (Placental Stage)

Stage One (Dilation)

Stage Two (Expulsion)

Stage Three (Placental Stage)

Management of a Management of a Patient Patient in Laborin 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.

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.

Field DeliveryField Delivery Set up delivery area. Give oxygen to

mother and start

IV-NS TKO. Drape mother with

toweling from OB kit. Monitor fetal heart

rate. As head crowns,

apply gentle pressure.

Set up delivery area. Give oxygen to

mother and start

IV-NS TKO. Drape mother with

toweling from OB kit. Monitor fetal heart

rate. As head crowns,

apply gentle pressure.

Suction the mouth and then the nose.

Clamp and cut the cord.

Dry the infant and keep it warm.

Deliver the placenta and save for transport with the mother.

Suction the mouth and then the nose.

Clamp and cut the cord.

Dry the infant and keep it warm.

Deliver the placenta and save for transport with the mother.

Neonatal CareNeonatal 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.

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.

Apgar ScoringApgar Scoring

Neonatal Neonatal ResuscitationResuscitation 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.

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.

Abnormal Delivery Abnormal Delivery SituationsSituations

Breech Breech PresentationPresentation 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.

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.

Prolapsed CordProlapsed 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.

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.

Limb Presentation Limb Presentation With limb With limb

presentation, place the presentation, place the mother in knee–chest mother in knee–chest position, administer position, administer

oxygen, and transport oxygen, and transport immediately. Do not immediately. Do not

attempt delivery.attempt delivery.

Other Abnormal Other Abnormal PresentationsPresentations

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.

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.

Other Delivery Other Delivery ComplicationsComplications

Multiple BirthsMultiple Births

Follow normal guidelines, but have additional personnel and equipment.

In twin births, labor starts earlier and babies are smaller.

Prevent hypothermia.

Follow normal guidelines, but have additional personnel and equipment.

In twin births, labor starts earlier and babies are smaller.

Prevent hypothermia.

Cephalopelvic Cephalopelvic DisproportionDisproportion

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 .

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 .

Precipitous Precipitous DeliveryDelivery 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.

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.

Shoulder DystociaShoulder 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.

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.

Meconium StainingMeconium 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.

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.

Maternal Maternal Complications of Complications of

Labor and DeliveryLabor and Delivery

Postpartum Postpartum HemorrhageHemorrhage 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.

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.

Uterine RuptureUterine 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.

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.

Uterine InversionUterine 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.

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.

Pulmonary Pulmonary EmbolismEmbolism 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.

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.