Obstetrics

1
Obstetrics

• Eileen M. Humphreys PA-C, EMT-I

2
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

3
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

4
Anatomy Review

• Mother and fetal blood do not mix in the
  umbilical cord
• Babys 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

5
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

6
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

7
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

8
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

9
Anatomy Review

• Perineum-area between the vagina and anus
• Can be torn during delivery

10
Obstetrics

• Increases seen in pregnancy
• Heart rate (10-15bpm)
• Respiratory rate
• Blood volume (plasma)
• Oxygen requirements

11
Obstetrics

• Decreases seen in pregnancy
• Blood pressure (10-15mmHg) by the end of the 1st
  trimester

12
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

13
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

14
Obstetrics

• When assessing trauma in pregnancy remember that
  most abdominal organs are displaced upward

15
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

16
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

17
1st 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

18
1st 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

19
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

20
2nd 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

21
2nd stage of labor

• Perineum bulges outward
• Crowning is noted

22
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

23
3rd stage of labor

• Placental stage
• Placenta separates from the uterine wall
• Usually occurs between 10-20 minutes after birth

24
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

25
Supine Hypotensive Syndrome

• Mothers body tries to compensate by rerouting
  blood flow away from the fetus to the mothers
  heart
• May cause fetal distress
• Mimics shock
• To treat place the mother and ALL 3rd trimester
  pregnancies on their left side

26
Obstetrics

• Transport any expecting mother unless you expect
  delivery within a few minutes
• Determined by the focused history and physical
  exam

27
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

28
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

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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

30
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

31
Obstetrics

• If delivery is suspected during transport then
  stop the ambulance
• Reassess the patient
• If crowning is noted then prepare for delivery

32
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

33
Delivery

• You are there to assist the mother
• Its 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

34
Delivery

• Monitor mothers vital signs and be prepared to
  suction
• When the babys 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

35
Delivery

• Support the babys 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

36
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

37
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

38
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

39
Delivery

• Help deliver the upper shoulder by gently guiding
  the babys 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

40
Delivery

• Avoid holding the newborn under the armpits as
  this may cause brachial plexus injuries

41
Delivery

• After delivery place the baby on its 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

42
Delivery

• Re-suction the mouth and nose
• Wrap the baby to keep it warm
• Note the time of birth

43
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

44
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

45
Assessing the Newborn

• General evaluation consists of
• Appearance
• Pulse
• Grimace
• Activity
• Respiration

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Assessing the Newborn

• APGAR
• At 1 and 5 minutes after birth
• Reveals trends in the infants condition
• Max points-10
• 2 points per assessment category

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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

48
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

49
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 its side and suction again
• Assess breathing-newborns should start breathing
  within 30 seconds of birth

50
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

51
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

52
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

53
Resuscitation of the newborn

• Chest compression depth is 1/2 inches
• Compression rate is 120/minute
• Wrap hands around infants torso and place thumbs
  on the lower 3rd of the sternum

54
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

55
General Care

• Keep the baby very warm
• Wrap the head since most heat loss occurs here
• Allow the mother to hold the baby

56
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

57
Obstetrics

• If the placenta does not deliver within 20
  minutes then transport
• Save everything and give to the hospital

58
Obstetrics

• Controlling vaginal bleeding after birth
• Around 500ccs 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

59
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

60
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

61
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

62
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 babys head
  to keep pressure off the cord
• Maintain position until you arrive at the
  hospital

63
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

64
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

65
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 infants size is small in proportion to the
  size of the mothers abdomen

66
Multiple births

• Usually the second infant will be in a breech
  presentation

67
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

68
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

69
Obstetric Emergencies

• Prebirth bleeding
• 2 types
• Placenta previa
• Abruptio placenta
• Both occur in the 3rd trimester
• Both are life-threatening

70
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

71
Placenta Previa

• Uterus is soft without tenderness to palpation
• present fetal heart tones and movement

72
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

73
Abruptio Placenta

• Abdomen is rigid with tenderness to palpation
• Fetal heart tones are absent
• Shock symptoms with/without major blood loss
  visible

74
Obstetric Emergencies

• Both require rapid transport with high flow O2

75
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

76
Ectopic pregnancy

• Signs and symptoms
• acute abdominal pain
• vaginal bleeding
• Shock
• Sudden sharp knife-like pain on one side

77
Ectopic pregnancy

• Patient care for ectopic pregnancies
• Position patient for shock
• High flow O2
• Keep NPO

78
Toxemia

• Preeclampsia-high blood pressure, swelling of the
  extremities, headaches, and visual disturbances
• Eclampsia-2nd stage of toxemia. Seizures occur

79
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

80
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

81
Obstetrics

• Abortion
• Occurs when the fetus is expelled before it can
  live on its own-usually before the 28th week
• 2 types
• Spontaneous abortion-miscarriage
• Induced abortion results from deliberate actions
  to stop the pregnancy

82
Obstetrics

• Signs and symptoms
• cramping abdominal pains
• moderate to severe bleeding
• noticeable discharge of tissue and blood from the
  vagina

83
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

84
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

85
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

86
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
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