Downloaded 16 times
More Related Content
![maternal guide presentation [Autosaved].pptx](https://cdn.slidesharecdn.com/ss_thumbnails/maternalpresentationautosaved-250208125838-a01bbc1b-thumbnail.jpg?width=640&height=640&fit=bounds)
More from djorgenmorris
OB- TCC
- 1. Paramedic Care: Principles &Practice Volume 6 Medical Emergencies
- 2.
- 3. Topics The Prenatal Period GeneralAssessment General Management Complications of Pregnancy Abnormal Delivery Situations Other Delivery Complications Maternal Complications of Labor and Delivery
- 4. Introduction Childbirth occurs daily,usually requiring only the most basic assistance Childbirth complications include: – Preterm labor, multiple births, abnormal presentations, bleeding, or distressed neonates Complications of pregnancy are uncommon – Hypertension, eclampsia, diabetes, cardiovascular, and trauma are causes
- 5.
- 6. The Prenatal Period Theprenatal period is the time from conception until delivery of the fetus. Significant physiological changes occur in the mother. – The result of fetal development
- 7. Anatomy and Physiologyof the Obstetric Patient Ovulation Fertilization – Normally occurs in the fallopian tube – Blastocyst forms Implants in the thickened uterine lining
- 8. Anatomy and Physiologyof the Obstetric Patient Placenta – Organ of pregnancy – Function Exchanges heat Exchanges oxygen for carbon dioxide Delivers nutrients Removes wastes – Endocrine function
- 9. Anatomy and Physiologyof the Obstetric Patient Uterus – Normal capacity 10 mL – By term 2 pounds 5 Liters Contains 1/6 of Mom’s blood volume
- 10. Anatomy and Physiologyof the Obstetric Patient Umbilical cord – Two arteries and one vein Vein transports oxygen rich blood Amniotic sac – “Bag of waters” – Contains amniotic fluid
- 11. Physiologic Changes of Pregnancy ReproductiveSystem – Uterus increases in size – Vascular system – Formation of mucous plug in cervix – Estrogen causes vaginal mucosa to thicken – Breast enlargement
- 12. Physiologic Changes of Pregnancy RespiratorySystem – Progesterone causes a decrease in airway resistance Results in a 20 percent increase in oxygen consumption and a 40 percent increase in tidal volume – Slight increase in respiratory rate
- 13. Physiologic Changes of Pregnancy CardiovascularSystem – Cardiac output increases – Blood volume increases Anemia – Supine hypotension
- 14. Physiologic Changes of Pregnancy GastrointestinalSystem – Hormone levels – Peristalsis is slowed Urinary System – Urinary frequency is common Musculoskeletal System – Loosened pelvic joints
- 15. Conception Normal duration of pregnancyis 40 weeks – Estimated date of confinement (EDC) – Trimesters Fetal Developmental Milestones
- 17. 2 Weeks Pregnant Momhas no clue yet Time of missed menstrual cycle Positive prego test
- 18. 4 Weeks Pregnant Fetalheart beating
- 19. 8 Weeks Baby 1.2inches long Mom feels like crap
- 20. 8-12 Weeks Mom stillfeels like crap Baby systems formed Making urine
- 21. 13 Weeks End of1st trimester Mom feels better Less risk of miscarriage
- 22. 16 Weeks Baby’s sexdetermined 2nd ultra sound
- 23. 20 Weeks Fetal hearttones present Baby 8 inches long; 16 ounces Baby kicking
- 24. 24 Weeks Baby breathingfluid Baby viable Baby over 1 pound
- 25. 28 Weeks Surfactant beingformed Baby 2 -3 pounds
- 26. 32 Weeks Baby 3– 4 pounds Baby getting some fat
- 27. 38 – 40Weeks Baby term
- 28. General Assessment of theObstetric Patient Physical Examination – Assess fundal height to determine gestation
- 30. Fetal Developmental Milestones Stages ofFetal Development – Pre-embryonic First 14 days following conception – Embryonic 15 days to 8 weeks – Fetal By 20 weeks fetal heart tones heard By 28 weeks, fetus is viable By 38 weeks, fetus is “term” © Phototake NYC
- 31. Fetal Circulation Umbilical veinsupplies blood to fetus – Connects directly to the inferior vena cava Ductus venosus – Foramen ovale – Ductus arteriosus Allows oxygenated blood to bypass the lungs of fetus – Changes at birth
- 33. General Assessment of theObstetric Patient
- 34. General Assessment of theObstetric Patient General Information – Mother’s gravidity and parity – Length of gestation – Estimated date of confinement (EDC) – Complications – Prenatal care – State of health
- 35. General Assessment of theObstetric Patient Preexisting or Aggravated Conditions – Diabetes Diabetics become unstable during pregnancy Larger baby – shoulder dystocia Gestational diabetes Must be treated with insulin Oral meds cross placenta – Heart Disease Congestive heart failure may develop
- 36. General Assessment of theObstetric Patient Preexisting or Aggravated Conditions (cont.) – Hypertension Common medications may not be used Pre-eclampsia may develop – Seizure Disorders Increased seizures – Neuromuscular Disorders Patients may have remission of symptoms during pregnancy
- 37. General Assessment of theObstetric Patient Pain – Determine when the pain started Sudden onset or slow – Duration, location, and radiation Vaginal Bleeding – Gain information about the color, amount, and duration Assess number of sanitary pads used – Transport any tissue or clots
- 38. General Assessment of theObstetric Patient Active Labor – Need to push? – Need to have BM? – Membranes ruptured? What did it look like?
- 39. General Assessment of theObstetric Patient Physical Examination (cont.) – Vital signs (lying on left side) – Evaluate: vaginal discharge progression of labor prolapsed cord crowning – Never perform an internal vaginal exam in the field.
- 40. General Management of theObstetric Patient
- 41. General Management of theObstetric Patient Always remember that you are caring for two patients, the mother and the fetus. Maintain the airway, breathing, and circulation. – Oxygen administration, IV access Patient positioning Transport considerations
- 42.
- 43. Complications of Pregnancy Trauma –Pregnant patients are more susceptible to life- threatening injury Increased vascularity of the gravid uterus Transport all trauma patients at 20 weeks or more gestation – Anticipate the development of shock Overt signs of shock are late – Direct abdominal trauma Premature separation of the placenta from the uterine wall, premature labor, abortion, uterine rupture, and possibly fetal death
- 44. Trauma Management Immobilize asnecessary Administer high-flow oxygen Initiate two large-bore IVs per protocol LSB tilted to the left to minimize supine hypotension Reassess patient Monitor the fetus
- 45. Medical Conditions Abdominal painis a common complaint – Appendicitis or cholecystitis Displacement of abdominal organs complicates assessment Symptoms of acute cholecystitis may differ from those in nonpregnant patients Any pregnant patient with abdominal pain should be evaluated by a physician.
- 46. Bleeding In Pregnancy Causes –Abortion – Ectopic Pregnancy – Placenta Previa – Abruptio Placentae Vaginal bleeding is associated with potential fetal loss
- 47. Abortion Termination of pregnancybefore the 20th week of gestation Assessment – Cramping, abdominal pain, backache, and vaginal bleeding – Passage of clots and tissue Management – Treat for shock – Provide emotional support
- 48. Ectopic Pregnancy Abnormal implantationof the fertilized egg outside of the uterus – Most commonly in the fallopian tube – Accounts for approximately 10 percent of maternal mortality
- 49. Ectopic Pregnancy Assessment – Presenceof abdominal pain – Woman often reports that she missed a period – The abdomen becomes rigid and the pain intensifies – Signs of shock Management – Transport this patient immediately – Treat for shock Consider use of PASG
- 50. Placenta Previa Abnormal implantationof the placenta on the lower half of the uterine wall Contractions pull placenta from uterine wall – Results in bleeding
- 51.
- 52. Placenta Previa Assessment – Usuallya multigravida in her third trimester of pregnancy May have history of placenta previa – Recent episode of sexual intercourse or vaginal examination – Painless bright red vaginal bleeding Management – Treat for shock – Transport to appropriate facility
- 53. Abruptio Placentae Premature separation(abruption) of a normally implanted placenta from the uterine wall
- 54.
- 55. Abruptio Placentae Predisposing factors –Multiparity, maternal hypertension, trauma, cocaine use, increasing maternal age, and history of abruption in previous pregnancy 20 to 30% fetal mortality – Increases to 100% when majority of the placenta has separated
- 56. Abruptio Placentae Assessment – Variesdepending on the extent and character Partial Marginal is characterized by vaginal bleeding but no increase in pain Central is characterized by sudden sharp, tearing pain and development of a stiff, board-like abdomen Complete Massive vaginal bleeding and profound maternal hypotension
- 57. Abruptio Placentae Management – Immediateintervention to maintain maternal oxygenation and perfusion Oxygenation and intravenous fluid therapy – Left-lateral recumbent position – Transport to appropriate facility
- 58. Medical Complications of Pregnancy HypertensiveDisorders Supine Hypotensive Syndrome Gestational Diabetes
- 59. Hypertensive Disorders of Pregnancy Pre-eclampsiaand Eclampsia – Mild or Severe – Increase in systolic blood pressure by 30 mmHg and/or a diastolic increase of 15 mmHg Two or more occasions – Most commonly seen in the last 10 weeks of gestation, during labor, or in the first 48 hours postpartum
- 60. Hypertensive Disorders of Pregnancy Preeclampsiaand Eclampsia (cont.) – Mild pre-eclampsia Hypertension, edema, and protein in the urine – Severe pre-eclampsia Maternal blood pressure reaches 160/110 or higher, generalized edema, large amounts of protein in urine Other symptoms include headache, visual disturbances, hyperactive reflexes, and the development of pulmonary edema
- 61. Hypertensive Disorders of Pregnancy Pre-eclampsiaand Eclampsia (cont.) – Eclampsia is characterized by SEIZURES – Patient is usually grossly edematous and has markedly elevated blood pressure
- 62. Hypertensive Disorders of Pregnancy Chronichypertension – Blood pressure is 140/90 before pregnancy or prior to the 20th week of gestation Chronic hypertension superimposed with pre-eclampsia Transient hypertension – A temporary rise in blood pressure which occurs during labor
- 63. Hypertensive Disorders of Pregnancy Assessment –Obtain history – Physical Exam Markedly edematous Pale and apprehensive Hypereactive reflexes Elevated blood pressure
- 64. Hypertensive Disorders of Pregnancy Management –Hypertension Closely monitor mother and fetus – Pre-eclampsia Keep the patient calm Dim the lights Left lateral positioning IV access Administration of magnesium sulfate – Eclampsia Administer oxygen Bolus dose of magnesium sulfate Diazepam as indicated
- 65. Supine Hypotensive Syndrome Graviduterus compresses the inferior vena cava – Mother in the supine position
- 66. Assessment – History ofsupine positioning – Patient may complain of dizziness – Question any recent hemorrhage or fluid loss Management – Place the patient in the left lateral recumbent position or elevate her right hip – Monitor fetal heart tones and maternal vital signs – Transport left-lateral recumbancy Supine Hypotensive Syndrome
- 67. Gestational Diabetes Hormonal influencescause an increase in insulin production – Initially, an increased tissue response to insulin – During the last 20 weeks placental hormones cause an increased resistance to insulin and decreased glucose metabolism Management requires good prenatal care
- 68. Gestational Diabetes Assessment – Alteredmental status Always suspect hypoglycemia – Diaphoresis, tachycardia, N/V, increased urination
- 69. Gestational Diabetes Management – Ifblood glucose less than 60 Obtain blood sample Administer D50% Consider oral glucose depending on patient LOC – If blood glucose greater than 200 Obtain blood sample Give fluid bolus of 1-2 liters Medical control may order insulin if delayed or long transport
- 70. Braxton-Hicks Contractions False labor Virtuallyimpossible to distinguish false labor from true labor in the field Transport patient for evaluation – Requires examination of the cervix WHICH WE DO NOT DO
- 71. Preterm 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
- 72. Preterm Labor Assessment – Determinethe approximate gestational age of the fetus <38 weeks is pre-term – Obtain a brief obstetrical history Ruptured membranes Need to push or move bowels Note the intensity and length of the contractions and contraction interval – Other common complaints
- 73. Preterm Labor Management – Pretermlabor should be stopped if possible Tocolysis Narcotic or barbiturate administration and rest Fluid bolus administration Magnesium sulfate or beta agonist administration – Tocolysis in the field is limited to sedation and hydration
- 74. Labor Stage One (Dilation) Stage Two (Expulsion) StageThree (Placental Stage)
- 75. Management of a Patientin Labor Transport the patient in labor unless delivery is imminent Considerations – Patient’s number of previous pregnancies – Length of labor during the previous pregnancies – Frequency of contractions – Maternal urge to push – Presence of crowning
- 76. Management of a Patientin Labor Factors indicating rapid transport despite imminent delivery – Prolonged rupture of membranes (> 24 hours) – Abnormal presentation, such as breech or transverse – Prolapsed cord or fetal distress – Multiple fetuses
- 77. Field Delivery Set updelivery 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
- 78.
- 79. Neonatal Care Routine neonatal care –Maintain warmth – Clear infant’s airway by suctioning mouth and nose – Assess the neonate using APGAR score
- 80.
- 81. Neonatal Resuscitation Factors thatcontribute to the need for resuscitation – Prematurity, pregnancy and delivery complications, maternal health problems, or inadequate prenatal care Tactile stimulation – If respiratory effort insufficient, assist ventilations with BVM and oxygen Reassess after 15-30 seconds Continue as necessary with ventilations
- 82. Neonatal Resuscitation Assess heartrate – Use a stethoscope to auscultate the apical pulse If the pulse is 100 or greater with spontaneous respirations, continue your assessment If less than 100 - VENTILATE If less than 60 - COMPRESSIONS
- 83. Neonatal Resuscitation Transport toappropriate facility Establish intravenous access – Umbilical vein – Peripheral vein – Intraosseous – Endotracheal drug administration for cardiac drugs Maintain warmth, support ventilations, oxygenation, and circulation enroute
- 84.
- 85. Abnormal Delivery Situations Breech ProlapsedCord Limb Presentation Other Abnormal Presentations
- 86.
- 87. Breech Presentation Either thebuttocks or both feet present first – Increased risk for delivery trauma to the mother – Increased potential for cord prolapse, cord compression, or anoxic insult for the infant
- 89. Breech Presentation Management – Positionthe mother with her buttocks at the edge of a firm bed Flex legs – Deliver the infants legs and support – As the head passes the pubis, apply gentle upward traction until the mouth appears over the perineum
- 90. Breech Presentation If headdoes not deliver: – Insert gloved hand with “V” fingers to move vaginal wall from airway
- 91. Breech Presentation Shoulder delivery –Gently rotate in an anterior-posterior position – Guide infants body upward Deliver posterior shoulder – Guide infant downward to deliver anterior shoulder
- 92. Prolapsed Cord Occurs whenthe umbilical cord precedes the fetal presenting part – Cord is compressed between the fetus and the bony pelvis Impedes circulation Predisposing factors – Prematurity – Multiple births – Premature rupture of the membranes
- 93.
- 94. Limb Presentation Baby isin a transverse lie across the uterus – Arm or leg is presenting part Predisposing factors – Preterm birth and multiple gestation Management – Under no circumstance should you attempt a field delivery – Assist the mother into a knee-chest position – Administer oxygen and transport immediately
- 95. Other Abnormal Presentations Occiput-posteriorpositioning – Passage through the pelvis is delayed Most frequent with primigravidas – Vaginal delivery is impossible in these cases Management – Early recognition – Reassure mother – Transport with oxygen administration
- 96.
- 97.
- 98. Other Delivery Complications MultipleBirths Cephalopelvic Disproportion Precipitous Delivery Shoulder Dystocia Meconium Staining
- 99. Multiple Births Multiple birthsshould also be suspected if the mother’s abdomen remains large after delivery of one baby and labor continues Management – Normal delivery guidelines Additional personnel necessary – Low birth weight increases chance of hypothermia Maintain warmth
- 100. Cephalopelvic Disproportion Infant’s headis too big to pass through pelvis easily – If not recognized, can cause uterine rupture Causes include oversized fetus, hydrocephalus, conjoined twins, or fetal tumors Management – Give oxygen to mother and start IV – Rapid transport
- 101. Precipitous Delivery Delivery occursin less than 3 hours of labor – Usually in patients in grand multipara – Complications Fetal trauma, tearing of cord, or maternal lacerations Management – Be ready for rapid delivery and attempt to control the head – Keep the baby warm
- 102. Shoulder Dystocia Infant’s shouldersare larger than its head – Most frequently with diabetic and obese mothers and in post-term pregnancies During delivery, head retracts back into perineum – Turtle sign
- 103. Shoulder Dystocia Management – Donot pull on the infant’s head – McRobert’s Manuever Flex legs, drop mother’s buttocks off bed Apply pressure to immediately above symphysis pubis – If delivery delayed, transport immediately
- 104.
- 105. Meconium Staining Fetus passesfeces into the amniotic fluid – Indicative of a fetal hypoxic incident – Risk of aspiration Management – Suction the mouth and nose on the perineum – If staining is light, no further care – If staining is thick: Visualize the glottis and suction the hypopharynx and trachea Utilize endotracheal tube
- 108. Maternal Complications of Laborand Delivery
- 109. Maternal Complications of Laborand Delivery Postpartum Hemorrhage Uterine Rupture Uterine Inversion Pulmonary Embolism
- 110. Postpartum Hemorrhage Defined asa loss of more than 500 cc of blood following delivery – Most common cause is uterine atony Multigravida Precipitous deliveries and prolonged labors – May occur up to 2 weeks post-delivery
- 111. Postpartum Hemorrhage Assessment – Relyon the clinical appearance of the patient and her vital signs – Assess number of sanitary pads used – “Boggy” uterus – Examine the perineum for evidence of traumatic injury
- 112. Postpartum Hemorrhage Management – Administeroxygen and begin fundal massage – Establish IV access – PASG – Administration of Pitocin may be indicated 10-20 units in 1 liter of NaCl Run at 125 cc/hr May administer 10 units intramuscularly, if necessary
- 113. Uterine Rupture Tearing, orrupture, 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 Management – Treat for shock – Give high-flow, high-concentration oxygen and start two large-bore IVs of normal saline – Transport patient rapidly
- 115. Uterine Inversion Uterus turnsinside out after delivery and extends through the cervix – Blood loss ranges from 800 to 1,800 cc Management – Place the patient in a supine position and begin oxygen administration – Begin fluid resuscitation – Make one attempt to replace the uterus – If unsuccessful, transport immediately with moist towels covering exposed uterus
- 117. Pulmonary Embolism Presents withsudden severe dyspnea and sharp chest pain – Tachycardia, tachypnea, jugular vein distention, and, in severe cases, hypotension Management – Administer high-flow, high-concentration oxygen and support ventilations as needed – Establish an IV of normal saline – Transport immediately, monitoring the heart, vital signs, and oxygen saturation