FCA 0313 Obstetrical Emergencies

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RMH Field Care Audit 03/13

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  • FCA 0313 Obstetrical Emergencies

    1. 1. Labor Intensive Veronica Bonales, M.D. RMH PCMDCEP America Emergency Physician
    2. 2. ObjectivesDiscuss the normal anatomy and physiology of pregnancyImportant parts of the history and physicalDelivering a babyComplications of Pregnancy
    3. 3. Anatomy and Physiology Kelly Clarkson
    4. 4. Normal Events of PregnancyOvulationFertilization Occurs in distal third of fallopian tubeImplantation Occurs in the uterus
    5. 5. Specialized Structures of PregnancyPlacentaUmbilical cordAmniotic sac and fluid
    6. 6. PlacentaTransfer of gasesTransport other nutrientsExcretion of wastesHormone productionProtection
    7. 7. Umbilical CordConnects placenta tofetusContains two arteriesand one vein Fetal circulation
    8. 8. Amniotic Sac and FluidMembrane surrounding thefetusFluid originates from fetalsources – urine, secretions Fluid accumulates rapidly Amounts to about 175 to 225 mL by the fifteenth week of pregnancy and about 1 L at birthRupture of the membraneproduces watery discharge
    9. 9. Fetal Growth and DevelopmentDuring the first 8 weeks of pregnancy the developingovum is known as an embryoAfter that and until birth it is called a fetus
    10. 10. Fetal Growth and DevelopmentThe period during which intrauterine fetal developmenttakes place (gestation) usually averages 40 weeks fromtime of fertilization to delivery Progress of gestation is usually considered in terms of 90-day periods or trimesters
    11. 11. Human embryo and fetus at 35 days
    12. 12. Human embryo and fetus at 49 days
    13. 13. Human embryo and fetusat end of first trimester
    14. 14. Human embryo and fetus at 4 months
    15. 15. Obstetrical TerminologyGravida – refers to the number of all of the womanscurrent and past pregnanciesPara – refers only to the number of the womans pastpregnancies that have remained viable to deliveryAntepartum – the maternal period before deliveryGestation – period of intrauterine fetal developmentGrand multipara – a woman who has had seven deliveriesor more
    16. 16. Obstetrical TerminologyMultigravida – a woman who has had two or morepregnanciesMultipara – a woman who has had two or more deliveriesNatal – connected with birthNullipara – a woman who has never deliveredPerinatal – occurring at or near the time of birthPostpartum – the maternal period after delivery
    17. 17. Obstetrical TerminologyPrenatal – existing or occurring before birthPrimigravida – a woman who is pregnant for thefirst timePrimipara – a woman who has given birth onlyonceTerm – a pregnancy that has reached 40 weeksgestation
    18. 18. Maternal Changes During PregnancyBesides cessation of menstruation and theobvious enlargement of the uterus, the pregnantwoman undergoes many other physiologicalchanges affecting the: Breasts Gastrointestinal system Cardiovascular system Respiratory system Metabolism
    19. 19. History and Physical Nicole Kidman
    20. 20. Obstetric HistoryLength of gestationParity and gravidityPrevious cesarean deliveryMaternal lifestyle (alcohol or other drug use, smokinghistory)Infectious disease statusHistory of previous gynecological or obstetricalcomplicationsPresence of pain
    21. 21. Obstetric HistoryPresence, quantity, and character of vaginal bleedingPresence of abnormal vaginal dischargePresence of “show” (expulsion of the mucous plug inearly labor) or rupture of membranesCurrent general health and prenatal care (none,physician, nurse midwife)
    22. 22. Obstetric HistoryAllergies, medications taken (especially theuse of narcotics in the last 4 hours)Maternal urge to bear down or sensation ofimminent bowel movement, suggestingimminent delivery
    23. 23. Physical ExaminationThe patients chief complaint determines the extent ofthe physical examination The prehospital objective in examining an obstetrical patient is to rapidly identify acute surgical or life-threatening conditions or imminent delivery and take appropriate management steps
    24. 24. Physical ExaminationEvaluate the patients general appearance skin colorAssess vital signs and frequently reassess them throughoutthe patient encounterExamine the abdomen for previous scars and any grossdeformity, such as that caused by a hernia or markedabdominal distention
    25. 25. Evaluation of Uterine SizeThe uterine contour is usually irregular between weeks8 and 10 Early uterine enlargement may not be symmetrical The uterus may be deviated to one sideAt 12 to 16 weeks, the uterus is above the symphysispubisAt 24 weeks, the uterus is at the level of the umbilicusAt term, the uterus is near the xiphoid process
    26. 26. Changes in fundal height in pregnancy, weeks 10 to 40
    27. 27. Fetal MonitoringFetal heart sounds may be auscultated between16 and 40 weeks by use of a stethoscope,fetoscope, or DopplerBenefits of fetal monitoringProcedureNormal fetal heart rate is 120 to 160 beats/min
    28. 28. Fetoscope
    29. 29. Doppler
    30. 30. Sites for Auscultation of Fetal Heart Tones
    31. 31. General Management of OB PatientIf birth is not imminent, care for thehealthy patient will often be limited tobasic treatment modalities
    32. 32. General Management of OB PatientIn the absence of distress or injury, transport the patientin a position of comfort (usually left lateral recumbent) ECG monitoring, high-concentration oxygen administration, and fetal monitoring may be indicated for some patients, based on patient assessment and vital sign determinations Medical direction may recommend IV access be established in some patients
    33. 33. Labor and Delivery
    34. 34. Stages of LaborStage 1 Begins with the onset of regular contractions and ends with complete dilation of the cervixStage 2 Measured from full dilation of the cervix to delivery of the infantStage 3 Begins with delivery of the infant and ends when the placenta has been expelled and the uterus has contracted
    35. 35. Parturition
    36. 36. Signs and Symptoms of Imminent DeliveryIf any of these signs and symptoms are present, preparefor delivery: Regular contractions lasting 45 to 60 seconds at 1‑ to 2‑ minute intervals The mother has an urge to bear down or has a sensation of a bowel movement There is a large amount of bloody show Crowning occurs The mother believes delivery is imminent
    37. 37. Signs and Symptoms of Imminent DeliveryExcept for cord presentation, the delay or restraint ofdelivery should not be attempted in any fashionIf complications are anticipated or an abnormaldelivery occurs, medical direction may recommendexpedited transport of the patient to a medical facilityPreparing for deliveryDelivery equipment
    38. 38. Prehospital Delivery Equipment
    39. 39. Assisting With DeliveryIn most cases, the paramedic only assists in thenatural events of childbirthPrimary responsibilities of the EMS crew: Prevent an uncontrolled delivery Protect the infant from cold and stress after the birth
    40. 40. Normal DeliveryAt crowning, apply gentle palm pressure to infant’s head
    41. 41. Normal DeliveryExamine neck for presence of looped umbilical cord
    42. 42. Normal DeliverySupport infant’s head as itrotates for shoulderpresentation
    43. 43. Normal DeliveryGuide infant’s headdownward todeliver anteriorshoulder
    44. 44. Normal DeliveryGuide infant’s headupward to releaseposterior shoulder
    45. 45. DeliveryAfter delivery and evaluation of infant, clamp and cut cord
    46. 46. Assisting with a Normal DeliveryDelivery procedureEvaluating the infantCutting the umbilical cordDelivery of the placentaInitiate fundal massage to promote uterinecontraction
    47. 47. Postpartum HemorrhageMore than 500 mL of blood loss afterdelivery of the newbornIncidenceCausesSigns and symptomsManagement
    48. 48. Delivery ComplicationsFactors associated with high risk ofabnormal delivery Maternal factors Fetal factors
    49. 49. Cephalopelvic DisproportionProduces a difficult labor because of the presence of asmall pelvis, an oversized fetus, or fetal abnormalities(hydrocephalus, conjoined twins, fetal tumors) The mother is often primigravida and experiencing strong, frequent contractions for a prolonged periodPrehospital care is limited to maternal oxygenadministration, IV access for fluid resuscitation if needed,and rapid transport to the receiving hospital
    50. 50. Abnormal Presentation Most infants are born head first(cephalic or vertex presentation) On rare occasions, a presentation is abnormalBreech presentation Management
    51. 51. Breech Presentations
    52. 52. Abnormal Presentation Cord presentation (prolapsedcord) Management
    53. 53. Abnormal PresentationGoals of prehospital management Early recognition of potential complications Maternal support and reassurance Rapid transport for definitive care
    54. 54. Premature BirthA premature infant is one born before37 weeks of gestationCare of the premature infant
    55. 55. Multiple GestationA pregnancy with morethan one fetusAssociated complicationsDelivery procedure
    56. 56. Precipitous DeliveryA rapid spontaneous delivery, with less than 3hours from onset of labor to birthResults from overactive uterine contractions andlittle maternal soft tissue or bony resistance
    57. 57. Uterine InversionAn infrequent but seriouscomplication of childbirthCausesSigns and symptomsManagement
    58. 58. Pulmonary EmbolismThe development of pulmonary embolismduring pregnancy, labor, or the postpartumperiod is one of the most common causes ofmaternal deathCausesSigns and symptomsManagement
    59. 59. Fetal Membrane DisordersPremature rupture of membranes A rupture of the amniotic sac before the onset of labor, regardless of gestational age Signs and symptoms include a history of a “trickle” or sudden gush of fluid from the vagina Transport for physician evaluationAmniotic fluid embolism May occur when amniotic fluid gains access to maternal circulation during labor or delivery or immediately after delivery Signs and symptoms Management
    60. 60. Meconium Staining Presence of fetal stool in amnioticfluid Incidence Assessment Management
    61. 61. Complications of Pregnancy Julia Roberts
    62. 62. Medical Conditionsand Disease Processes
    63. 63. Preeclampsia and EclampsiaPreeclampsia A disease of unknown origin that primarily affects previously healthy, normotensive primigravidae Occurs after the twentieth week of gestation, often near term Pathophysiology Signs and symptomsEclampsia Characterized by the same signs and symptoms plus seizures or coma
    64. 64. Preeclampsia and EclampsiaThe criteria for diagnosis of preeclampsia are based onthe presence of the “classic triad” Hypertension (blood pressure greater than 140/90 mm Hg, an acute rise of 20 mm Hg in systolic pressure, or a rise of 10 mm Hg in diastolic pressure over pre-pregnancy levels) Proteinuria Excessive weight gain with edemaPredisposing factorsManagement
    65. 65. TB 031413
    66. 66. Vaginal Bleeding
    67. 67. AG 022213
    68. 68. AG 022213
    69. 69. AbortionThe termination of pregnancy from any cause before thetwentieth week of gestation (after which it is known as apreterm birth)Common classifications of abortionWhen obtaining a history, determine The time of onset of pain and bleeding Amount of blood loss If the patient passed any tissue with the bloodManagement
    70. 70. Ectopic PregnancyOccurs when a fertilized ovum implants anywhereother than the endometrium of the uterine cavityIncidencePredisposing factorsClassic triad of symptoms Abdominal pain Vaginal bleeding AmenorrheaManagement
    71. 71. Third‑trimester Bleeding
    72. 72. Abruptio PlacentaeA partial or complete detachment of a normally implanted placentaat more than 20 weeks gestationPredisposing factorsSigns and symptoms
    73. 73. Placenta PreviaPlacental implantation in the lower uterine segment encroaching onor covering the cervical osCausesSigns and symptoms
    74. 74. Uterine RuptureA spontaneous or traumatic rupture of the uterinewallCausesSigns and symptoms
    75. 75. Management of Third-trimester BleedingPrehospital management of a patient withthird‑ trimester bleeding is aimed at preventingshockNo attempt should be made to examine thepatient vaginally Doing so may increase hemorrhage and precipitate laborEmergency care
    76. 76. Trauma in PregnancyCauses of maternal injury in decreasing order offrequency: Vehicular crashes Falls Penetrating objectsThe greatest risk of fetal death is from fetal distressand intrauterine demise caused by trauma to themother or her death
    77. 77. Trauma in PregnancyWhen dealing with a pregnant trauma patient,promptly assess and intervene on behalf of the motherCauses of fetal death from maternal traumaAssessment and managementSpecial management considerationsTransportation strategies
    78. 78. MA 121912
    79. 79. MA 122512PATIENT BROUGHT INTO ED VIA EMS FOR CARDIAC ARRESTROSC HOWEVER FETAL DISTRESS NOTED CRASH C-SECTION PERFORMED IN ED FETAL DEMISE MOTHER TO ICU, CRITICAL LIFE SUPPORT REMOVED
    80. 80. Questions??KEITH URBAN
    81. 81. ObjectivesDiscuss the normal anatomy and physiology of pregnancyImportant parts of the history and physicalDelivering a babyComplications of Pregnancy
    82. 82. EMS CASESSt. Thomas, USVI
    83. 83. KG 021513
    84. 84. KG 021513
    85. 85. CH 022313
    86. 86. CH 022313Discuss
    87. 87. TS 021813
    88. 88. TS 021813
    89. 89. TS 021813
    90. 90. TS 021813
    91. 91. TS 021813
    92. 92. St. Thomas, USVI QuickTime™ and a H.264 decompressor are needed to see this picture.

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