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
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
The Prenatal Period The prenatal period is thetime from conception until delivery of the fetus.
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.
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.
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.
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
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.
Trauma Transport all trauma patientsat 20 weeks or more gestation.Anticipate the development of shock.
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.
Medical ConditionsAny pregnant patient withabdominal pain should beevaluated by a physician.
Causes of Bleeding During Pregnancy Abortion Ectopic pregnancy Placenta previa Abruptio placentae
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.
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.
Placenta Previa Usually presents with painless bleeding. Never attempt vaginal exam. Treat for shock. Transport immediately— treatment is delivery by c-section.
Abruptio Placentae Signs and symptoms vary. Classified as partial, severe, or complete. Life-threatening. Treat for shock, fluid resuscitation. Transport left lateral recumbent position.
Medical Complications of Pregnancy Hypertensive Disorders Supine Hypotensive Syndrome Gestational Diabetes
Hypertensive Disorders Preeclampsia and Eclampsia Chronic Hypertension Chronic Hypertension Superimposed with Preeclampsia Transient Hypertension
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.
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.
Braxton-Hicks Contractions False labor that increases inintensity and frequency but does not cause cervical changes
The PuerperiumPuerperium—the time period surrounding the birth of the fetus
Labor Stage One (Dilation) Stage Two (Expulsion) Stage Three (Placental Stage)
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.
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.
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.
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.
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.
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.
Limb PresentationWith limb presentation, place the mother in knee–chestposition, administer oxygen,and transport immediately. Do not attempt delivery.
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.
Multiple Births Follow normal guidelines, but have additional personnel and equipment. In twin births, labor starts earlier and babies are smaller. Prevent hypothermia.
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 .
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.
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.
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.
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.
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.
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.
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.