Transcript Chapter 41: Obstetrics - Jones & Bartlett Learning

Chapter 41
Obstetrics
National EMS Education
Standard Competencies
Special Patient Populations
Integrates assessment findings with principles
of pathophysiology and knowledge of
psychosocial needs to formulate a field
impression and implement a comprehensive
treatment/disposition plan for patients with
special needs.
National EMS Education
Standard Competencies
Obstetrics
• Recognition and management of
− Normal delivery
− Vaginal bleeding in the pregnant patient
• Anatomy and physiology of normal
pregnancy
National EMS Education
Standard Competencies
Obstetrics
• Pathophysiology of complications of
pregnancy
• Assessment of the pregnant patient
National EMS Education
Standard Competencies
Obstetrics
• Psychosocial impact, presentations,
prognosis, and management of
− Normal delivery
− Abnormal delivery
• Nuchal cord
• Prolapsed cord
• Breech delivery
National EMS Education
Standard Competencies
Obstetrics
• Psychosocial impact, presentations,
prognosis, and management of (cont’d)
− Third-trimester bleeding
• Placenta previa
• Abruptio placenta
− Spontaneous abortion/miscarriage
National EMS Education
Standard Competencies
Obstetrics
• Psychosocial impact, presentations,
prognosis, and management of (cont’d)
−
−
−
−
Ectopic pregnancy
Preeclampsia/eclampsia
Antepartum hemorrhage
Pregnancy-induced hypertension
National EMS Education
Standard Competencies
Trauma
Integrates assessment findings with principles
of epidemiology and pathophysiology to
formulate a field impression to implement a
comprehensive treatment/disposition plan for
an acutely injured patient.
National EMS Education
Standard Competencies
Special Considerations in Trauma
• Recognition and management of trauma in
− Pregnant patient
− Pediatric patient
− Geriatric patient
National EMS Education
Standard Competencies
Special Considerations in Trauma
• Pathophysiology, assessment, and
management of trauma in the
−
−
−
−
Pregnant patient
Pediatric patient
Geriatric patient
Cognitively impaired patient
Introduction
• Pregnancy is not a disease needing
treatment.
− Childbirth is usually a happy event.
• The number of patients increases from one
to a minimum of two.
Anatomy and Physiology of the
Female Reproductive System
• Female reproductive organs include:
− Mammary glands
− Vagina
− Uterus
− Ovaries
− Fallopian tubes
Anatomy and Physiology of the
Female Reproductive System
• Each ovary contains about 200,000 follicles,
with each one containing an oocyte.
− Each month, about 20 of the follicles begin the
maturation process.
− Only a single follicle releases an ovum.
Anatomy and Physiology of the
Female Reproductive System
• The cycle continues with the release of
hormones throughout various stages.
− The anterior pituitary gland releases:
• Follicle-stimulating hormone (FSH)
• Luteinizing hormone (LH)
− At the end of pregnancy, prostaglandins and
oxytocin signal uterine contractions and labor.
Anatomy and Physiology of the
Female Reproductive System
© Nestle/Petit Format/Photo Researchers, Inc.
− Secretes
progesterone to
begin second
phase
− The egg can then
develop into an
embryo and then a
fetus.
© Claude Cortier/Photo Researchers, Inc.
• Corpus luteum:
what is left of the
follicle after the
egg is released
Anatomy and Physiology of the
Female Reproductive System
• The ovum travels from the ovaries into the
uterus through the fallopian tubes.
• Composed of three tissue layers:
− Outer layer protects the tubes
− Middle layer helps ovum move into uterus
− Innermost layer helps move the ovum and
provide nutrition
Anatomy and Physiology of the
Female Reproductive System
• Uterus: organ that lies between the urinary
bladder and the rectum
− The uterus is where:
• The fertilized ovum will implant.
• The fetus will develop.
• Labor takes place.
Anatomy and Physiology of the
Female Reproductive System
• Three layers of tissues in the uterus:
− Perimetrium
− Myometrium
− Endometrium
Anatomy and Physiology of the
Female Reproductive System
• Vagina: highly muscular organ lined with
mucous membranes
− Functions include:
• Receptacle for penis during sexual intercourse
• Passage for exit of menstrual flow
• Passage for childbirth
Anatomy and Physiology of the
Female Reproductive System
• The vagina is the lower portion of the birth
canal.
− Stretches to accommodate fetus delivery
− If it doesn’t stretch enough:
• Tissues in and around perineum can tear.
• Significant pain and bleeding may occur.
Anatomy and Physiology of the
Female Reproductive System
• Mammary glands: modified sweat glands
− Primary purpose: lactation
− Signs that a woman is most likely pregnant:
• Breast enlargement
• Tenderness
• Milk excretion
Conception and Fetal
Development
• Once the egg has been fertilized and
implanted, major changes occur.
− Cells multiply on outside of the egg surface,
forming layers that will generate:
• Fetal membrane
• Placenta
• Embryo
Conception and Fetal
Development
• Blastocyst migrates to the endometrial wall
and becomes implanted a week after
conception.
− Triggers the development of placental tissues
− The corpus luteum produces hormones to
support pregnancy until placenta develops.
Conception and Fetal
Development
• Two weeks after
conception:
− The blastocyst
evolves into an
embryonic disc.
− The embryo begins
to draw on maternal
circulation.
• Three weeks after
conception:
− The blastocyst
officially becomes an
embryo.
− Body systems form.
− The heart beats.
− Blood cells circulate.
Conception and Fetal
Development
• In the fourth week of pregnancy, the
placenta develops.
− Serves as an early liver
− Produces antibodies
− Functions as fetal lungs
− Transports nutrients and excretes wastes
Conception and Fetal
Development
• The umbilical cord
connects the fetus
and placenta.
− The umbilical vein
carries blood to the
fetus.
− The umbilical
arteries carry blood
to the placenta.
Conception and Fetal
Development
• The amniotic sac encloses the fetus in
amniotic fluid.
• The fourth through eighth week of
embryonic development are critical.
− Major organs and other body systems are most
susceptible to damage as they form.
Conception and Fetal
Development
• Gestational period: time it takes the fetus to
develop in utero
− Normally 38 weeks
− Calculated from the first day of the pregnant
woman’s last menstrual period
Physiologic Maternal Changes
During Pregnancy
• Physiologic changes occurring throughout
pregnancy can:
− Alter normal response to trauma.
− Exacerbate or create medical conditions.
Physiologic Maternal Changes
During Pregnancy
• Significant changes occur in the uterus.
− Before pregnancy, the uterus:
• Weighs about 0.07 oz (2 g)
• Has a fluid capacity of about 10 mL
− At the end of the pregnancy, the uterus:
• Weighs as much as 2.2 lb (1 kg)
• Has the capacity to hold about 5,000 mL
Physiologic Maternal Changes
During Pregnancy
• Measurement of
the fundus may
indicate
developmental
problems.
− If different than
expected, it could
indicate:
• Uterine growth
problems or
breech position
• Possibility of twins
Physiologic Maternal Changes
During Pregnancy
• Pressure occurs on intestine and rectum.
• Smooth muscle in the GI tract relaxes.
• Kidneys increase in size and volume.
• Ureters increase in diameter.
• Hormones cause changes to the skin, hair,
and eyes.
Physiologic Maternal Changes
During Pregnancy
• Circulatory changes
− Blood volume increases up to 50% more to:
• Meet fetal metabolic needs.
• Adequately perfuse maternal organs.
• Help compensate for blood loss in delivery.
Physiologic Maternal Changes
During Pregnancy
• Circulatory changes (cont’d)
− Number of red blood cells increases.
− Clotting factors increase while fibrinolytic factors
are depressed.
− Size of heart increases.
• Cardiac output increases to about 40% more.
Physiologic Maternal Changes
During Pregnancy
• Heart rate gradually increases by an
average of 15 to 20 beats/min by term.
− ECG changes may include:
• Ectopic beats
• Supraventricular tachycardia
• Slight left axis deviation
• Lead II changes
Physiologic Maternal Changes
During Pregnancy
• Sensitivity to body position increases as
gestation increases.
− Lying supine can cause compression of the
inferior vena cava.
− If pressure is not relieved, cardiac output is
decreased.
Physiologic Maternal Changes
During Pregnancy
• The birthing
position may stress
the cardiovascular
system.
− The lithotomy
position is standard
in the United
States.
Physiologic Maternal Changes
During Pregnancy
• Respiratory changes
− The diaphragm is pushed up by the uterus.
− Maternal oxygen demand increases.
− Progesterone:
• Decreases threshold to carbon dioxide
• Causes the bronchi to dilate
• Regulates mucus production
Physiologic Maternal Changes
During Pregnancy
• Respiratory changes (cont’d)
− A decrease in:
• Expiratory reserve volume
• Functional residual capacity
• Residual volume
− An increase in:
• Tidal volume
• Inspiratory reserve volume
Physiologic Maternal Changes
During Pregnancy
• Maternal metabolism
− Weight gain averages 27 lb (12.3 kg).
• Increased blood volume and intracellular and
extracellular fluid
• Uterine growth
• Placental and fetal growth
• Increased breast tissue
• Increased proteins and fat deposits
Physiologic Maternal Changes
During Pregnancy
• Maternal metabolism
− Relaxin softens collagenous tissues and relaxes
the ligamentous system.
− Demand for carbohydrates increases.
• Several hormones help compensate.
Cultural Value Considerations
• Some cultures may have a value system
that affects their pregnancy.
• Some cultures may not permit a male health
care provider to examine a pregnant
patient.
• Different cultures view pregnancy
differently.
Adolescent Pregnancy
• United States has one of the highest
teenage pregnancy rates compared with
other developed countries.
• Pregnancy is a possibility when assessing
all female teenagers.
Patient Assessment
• Special terminology:
− Gravidity—number of times pregnant
− Parity—delivery of an infant who is alive
− Primigravida—woman pregnant for first time
− Primipara—woman with only one delivery
− Multigravida—two or more pregnancies
Patient Assessment
• Special terminology (cont’d):
− Multipara—two or more deliveries
− Grand multipara—more than five deliveries
− Nullipara—never delivered
Scene Size-Up
• Take standard precautions.
• Consider calling for specialized resources.
• Determine mechanism of injury or nature of
illness.
Primary Assessment
• Form a general impression.
− Determine if there is time for further evaluation.
− Perform a rapid scan for ABC problems.
− Evaluate trauma or other medical problems first.
− Use the AVPU scale to determine level of
consciousness.
Primary Assessment
• Airway and breathing
− Generally not an issue in uncomplicated birth
− If trauma, assess for airway and breathing.
• Circulation
− Assess early for internal and external bleeding.
− Assess for signs of shock and control bleeding.
Primary Assessment
• Transport decision
− If imminent, prepare to deliver at the scene.
− If not imminent, transport the woman lying on
the left side when possible.
Primary Assessment
• Transport decision (cont’d)
− Provide rapid transport for patients:
• With significant bleeding and pain
• Who are hypertensive
• Who are having a seizure
• Who have an altered mental status
History Taking
• Determine chief complaint using OPQRST.
• Obtain the SAMPLE history.
• Determine estimated due date.
• Determine previous complications or
gynecologic problems.
History Taking
• Was an ultrasound done recently, and what
were the findings?
• Determine the general impression of the
patient’s health.
• Determine if there is any vaginal bleeding.
History Taking
• Determine if the woman’s water has broken.
− Does she need to move her bowels or push?
• Delivery is imminent.
• Inspect the woman for crowning.
Secondary Assessment
• Base the exam on the chief complaint.
− Exam should include fetal heart tones and rate.
• Inspect for crowning or vaginal bleeding.
• If the water has broken, ask about the color
of the fluid.
Secondary Assessment
• Imminent delivery
− Assess the woman’s vital signs.
− Estimate the gestational age.
− Listen for fetal heart tones.
Secondary Assessment
• If there is time to
reach the hospital:
− Place in the lateral
recumbent position.
− Remove clothing that
might obstruct
delivery.
− Begin transport.
• If there is not time:
− Try to find a private
and clean area.
− Keep nervous
bystanders busy.
− Be calm and
professional.
Reassessment
• Perform ongoing examination, including:
− Serial vital signs
− Fetal heart rate and heart tones
• Time contractions, and perform exam.
• Check interventions, and transport.
Reassessment
• If delivery is imminent:
− Notify staff at hospital.
− Provide an update on the status after delivery.
• If delivery does not occur with 30 minutes or
a complication occurs:
− Notify staff.
− Provide rapid transport.
Substance Abuse
• Illicit drugs pass through the placenta
barrier and enter fetal circulation.
• The fetus may have withdrawal signs.
• Treatment should concentrate on
cardiorespiratory support.
Supine Hypotensive Syndrome
• Uterus may compress the inferior vena
cava.
• Can result in significant hypotension and
fetal distress
Supine Hypotensive Syndrome
• Management includes:
− Place patient in left lateral recumbent position.
− Treat underlying causes.
− Monitor blood pressure and other vital signs.
− Obtain an ECG.
Cardiac Conditions
• Determine the nature and treatment of any
heart condition.
− Cardiac medications?
− Diagnosed with dysrhythmias or heart
murmurs?
− History of rheumatic fever?
− Born with congenital heart defect?
− Episodes of dizziness, light-headedness?
Hypertensive Disorders
• Chronic hypertension
− Blood pressure equal
to or greater than
140/90 mm Hg
− Increased risk for
stroke or other
cardiovascular
problems
• Pregnancy-induced
hypertension
− Develops after the
20th week of
pregnancy
− Resolves
spontaneously
Hypertensive Disorders
• Preeclampsia
− Risk factors include:
• First pregnancy before age 20 years
• Women with advanced maternal age
• History of multiple pregnancies
• Diabetes
Hypertensive Disorders
• Preeclampsia (cont’d)
− Manifests after 20th week with a triad of
symptoms including:
• Edema
• Gradual onset of hypertension
• Protein in the urine
Hypertensive Disorders
• Preeclampsia (cont’d)
− Chronic hypertension can:
• Retard growth and development of the fetus.
• Impair liver and renal function.
• Cause pulmonary edema.
• Progress to life-threatening grand mal seizures.
Seizures
• Treatment is difficult because drugs may
cause fetal distress.
− Magnesium sulfate is recommended.
• Potential complications may include:
− Abruptio placenta
− Hemorrhage
− Disseminated intravascular coagulation
Diabetes
• Gestational diabetes mellitus (GDM):
inability to process carbohydrates during
pregnancy
• May be asymptomatic or exhibit the same
signs as patients with diabetes mellitus
• Treatment consists of:
− Diet control
− Oral hypoglycemic medications
Diabetes
• Diabetes may be affected by pregnancy.
− May manifest as hyperglycemic or
hypoglycemic episodes
− Insulin-dependent diabetics may need to adjust
their dosages during pregnancy.
• Patients with a history of diabetes should
have a blood glucose level test.
Respiratory Disorders
• Shortness of breath or general dyspnea is
one of the most common complaints.
− Often caused by hormone-related changes
• Asthma is a common condition that
complicates pregnancy.
Respiratory Disorders
• Maternal asthma
complications:
• Fetal asthma
complications:
− Premature labor
− Preeclampsia
− Premature birth
− Low birth rate
− Respiratory failure
− Vaginal hemorrhage
− Growth retardation
− Fetal death
− Eclampsia
Respiratory Disorders
• Pneumonia
− Especially virulent during pregnancy
− Common complications:
• Low birth weight
• Premature labor
• Preterm delivery
Hyperemesis Gravidarum
• Persistent nausea and vomiting
− Leads to dehydration and malnutrition
• Exact cause is unknown.
• Symptoms include:
− Severe and persistent vomiting
− Projectile vomiting
− Severe nausea
Hyperemesis Gravidarum
• Prehospital treatment includes:
− Administer 100% supplemental oxygen.
− Start IV line of normal saline.
− If protocols allow, administer diphenhydramine.
− Check blood glucose levels.
− Check orthostatic vital signs; obtain an ECG.
− Transport to a hospital.
Renal Disorders
• During pregnancy, a woman’s kidneys
increase in length and ureters get longer.
− Changes can lead to urinary stasis and urinary
tract infections.
• The uterus puts pressure on the bladder,
causing increased urinary frequency.
Rh Sensitization
• If the mother is Rh negative and the father
is Rh positive, the fetus may inherit Rh
factor.
− The fetal blood can enter the woman’s
circulation and produce a maternal antibody to
the factor.
• In subsequent pregnancies the antibodies will attack
the fetal RBCs.
Infections
• Urinary tract infections
− If Streptococcus agalactiae is passed to the
newborn, it can cause:
• Respiratory problems
• Pneumonia
• Septic shock
• Meningitis
Infections
• Human immunodeficiency virus (HIV)
− Pregnant women may infect their fetus:
• During pregnancy
• During delivery
• From breastfeeding
Infections
• Cholestasis
− If the bile cannot flow normally, it builds up in
the liver and spills into the bloodstream.
− Symptoms include:
• Profuse, painful itching
• Right upper quadrant pain
• Color changes in waste elimination
Infections
• Cholestasis (cont’d)
− High risks include:
• Carrying multiple fetuses
• A familial history of cholestasis
• Previous liver damage
Sexually Transmitted
Infections
• Bacterial vaginosis
− Normal vaginal bacteria are replaced by other
bacteria.
− Can lead to:
• Premature birth
• Low birth weight
• Pelvic inflammatory disease
Sexually Transmitted
Infections
• Candidiasis
− Risk factors include:
• Poorly controlled diabetes
• Taking antibiotics
• Wearing tight-fitting clothing
• Activities causing irritation
Sexually Transmitted
Infections
• Candidiasis (cont’d)
− Treatment includes:
• Prescription creams and over-the-counter
medications
− Fetus may develop thrush in the mouth if
infection is active during delivery or if the
woman breastfeeds.
Sexually Transmitted
Infections
• Chlamydia
− Symptoms are usually mild or absent.
− Can spread to the rectum, causing:
• Rectal pain
• Discharge
• Bleeding
− Can progress to pelvic inflammatory disease
Sexually Transmitted
Infections
• Gonorrhea
− Bacterial infection that multiplies rapidly
− Symptoms include:
• Dysuria with burning or itching
• Yellowish or bloody vaginal discharge
• Bleeding with vaginal intercourse
Sexually Transmitted
Infections
• Human papilloma virus (HPV)
− May cause warts or be asymptomatic
− Warts may affect urination or obstruct birth
canal.
− The fetus may develop laryngeal papillomatosis.
Sexually Transmitted
Infections
• Syphilis
− May remain asymptomatic for years
− Primary stage: single sore
− Stage two: lesions, skin rash
− Late stage: no signs or symptoms, but disease
attacks the body
Sexually Transmitted
Infections
• Syphilis (cont’d)
− Women with syphilis may have:
• Stillborn babies
• Babies born blind
• Developmentally delayed babies
• Babies who die shortly after birth
Sexually Transmitted
Infections
• Trichomoniasis
− May be asymptomatic or have signs and
symptoms including:
• Frothy, yellow-green vaginal discharge
• Irritation and itching
• Discomfort during intercourse
• Dysuria
• Lower abdominal pain
Sexually Transmitted
Infections
• Trichomoniasis (cont’d)
− If a pregnant woman is not treated, there is an
increased chance of:
• Low birth weight newborn
• Premature birth
• Increased susceptibility to HIV infection
TORCH Syndrome
• TORCH—toxoplasmosis, other agents,
rubella, cytomegalovirus, and herpes
simplex
• Refers to infections that pass through the
placenta to the fetus
TORCH Syndrome
• Toxoplasmosis
− Caused from handling or eating contaminated
food or from handling cat litter
− If early in the pregnancy, there is a decreased
chance of passing it on to the fetus.
TORCH Syndrome
• Rubella
− If less than 20 weeks gestation, there is a
significant chance of developmental problems
with the fetus.
− Fetal adverse effects include:
• Being born blind or deaf
• Significant cardiac and respiratory abnormalities
TORCH Syndrome
• Cytomegalovirus (CMV)
− A member of the herpes virus family
− Can remain dormant in the body for years
− Pregnant women have an increased risk for
active infection and more serious complications.
TORCH Syndrome
• Cytomegalovirus (CMV) (cont’d)
− Newborns with CMV are susceptible to:
• Lung problems
• Blood problems
• Liver problems
• Swollen glands
• Rash
• Poor weight gain
TORCH Syndrome
• Herpes
− Infection of the genitals, buttocks, or anal area,
caused by herpes simplex virus type 1 or type 2
− Symptoms may include:
• Tingling or sores
• Muscle aches and pain
• Swollen glands in the groin area
Pathophysiology of Bleeding
Related to Pregnancy
• Abortion
− Expulsion of the fetus before the 20th week of
gestation
− Broadly classified as:
• Spontaneous abortion (miscarriage)
• Elective (intentional) abortion
Pathophysiology of Bleeding
Related to Pregnancy
• Habitual abortions: three or more
consecutive miscarriages
− Causes include:
• Ovarian issues
• Uterine malformations
• Cervical conditions
Pathophysiology of Bleeding
Related to Pregnancy
• Threatened abortion: abortion attempting to
take place
− Characterized by vaginal bleeding in the first
half of pregnancy
− Can progress or may subside
− Prehospital role is transport and support.
Pathophysiology of Bleeding
Related to Pregnancy
• Imminent abortion: spontaneous abortion
that cannot be prevented
− Signs and symptoms include:
• Severe abdominal pain
• Vaginal bleeding
• Cervical dilation
Pathophysiology of Bleeding
Related to Pregnancy
• Imminent abortion (cont’d)
− Treatment includes:
• Establishing an IV line of normal saline
• Administering 100% supplemental oxygen
• Obtaining an ECG
• Providing emotional support with rapid transport
• Watching for signs of shock
Pathophysiology of Bleeding
Related to Pregnancy
• Incomplete abortion: part of the products of
conception remains in the uterus
− Vaginal bleeding will be continuous.
− Start an IV line of normal saline.
− Consult medical control.
− Collect all products of conception.
Pathophysiology of Bleeding
Related to Pregnancy
• Missed abortion: fetus dies during the first
20 weeks of gestation but remains in utero
− Provide emotional support and transport.
− On examination:
• Uterus feels like a hard mass.
• Fetal heartbeat cannot be heard.
Pathophysiology of Bleeding
Related to Pregnancy
• Septic abortion: uterus becomes infected
following abortion
− History includes fever and bad-smelling vaginal
discharge after abortion.
− Physical examination shows fever and
abdominal tenderness.
Pathophysiology of Bleeding
Related to Pregnancy
• Septic abortion (cont’d)
− Prehospital management includes:
• Establishing an IV line of normal saline
• Administering 100% supplemental oxygen
• ECG monitoring
• Rapid transport
• Fluid administration
Pathophysiology of Bleeding
Related to Pregnancy
• Third-trimester bleeding
− Greatest danger of hemorrhage
• Large volume of blood present
• Compensatory mechanisms function as a result of
pregnancy.
Pathophysiology of Bleeding
Related to Pregnancy
• Ectopic pregnancy
− Ovum implants somewhere besides uterus.
− Patient usually presents with:
• Severe abdominal pain
• May be in hypovolemic shock
Pathophysiology of Bleeding
Related to Pregnancy
• Ectopic pregnancy (cont’d)
− All female patients of child-bearing age should
be considered.
− Treat for shock, and provide rapid transport.
Pathophysiology of Bleeding
Related to Pregnancy
• Abruptio placenta
− Premature
separation of the
placenta from the
uterine wall
Pathophysiology of Bleeding
Related to Pregnancy
• Abruptio placenta (cont’d)
− Patient will report:
• Vaginal bleeding with bright red blood
• Sudden onset of severe abdominal pain
• No longer feeling the fetus moving
Pathophysiology of Bleeding
Related to Pregnancy
• Abruptio placenta (cont’d)
− Physical examination will show:
• Signs of shock
• Tender abdomen and rigid uterus
• Fetal heart sounds may be absent.
Pathophysiology of Bleeding
Related to Pregnancy
• Placenta previa
− Placenta is
implanted low in
the uterus and
obscures the
cervical canal.
Pathophysiology of Bleeding
Related to Pregnancy
• Placenta previa (cont’d)
− Chief complaint is usually painless vaginal
bleeding with bright red blood.
− The uterus is soft and nontender.
Assessment of Bleeding
Related to Pregnancy
• Try to determine the nature of the bleeding.
• Use OPQRST to elaborate on the chief
complaint of labor pain.
• Identify changes in orthostatic vital signs.
• Look for positive Grey Turner or Cullen
sign.
Management of Bleeding
Related to Pregnancy
• Keep the woman lying on her left side.
• Administer 100% supplemental oxygen.
• Provide rapid transport.
• Start an IV line of normal saline.
• Obtain an ECG and baseline vital signs.
• Loosely place trauma pads over the vagina.
Stages of Labor
• First stage
− Begins with onset of labor pains
− Lasts until cervix is fully dilated
− Toward the end of the stage, the amniotic sac
often ruptures.
Stages of Labor
• Second stage
− Begins as the head descends to enter birth
canal
− Fetus will undergo several position changes.
• Internal rotation
• Extension
• Rotation to the side
• Movement of the shoulders
Stages of Labor
• Second stage (cont’d)
− Contractions are more intense and frequent.
− The cervix becomes fully dilated.
− Concluded when the newborn is fully delivered
Stages of Labor
• Third stage of labor
− Placenta is expelled.
− Uterine contractions squeeze shut the exposed
blood vessels.
Maternal and Fetal Response
to Labor
• Maternal response
− Increase in:
• Workload of the heart
• Blood pressure, pulse, and cardiac output
• Breathing rate
• WBC production
Maternal and Fetal Response
to Labor
• Fetal response
− Decrease in the amount of oxygen and nutrients
− Insufficient removal of waste
− Decreased fetal heart rate
− Fetal acidosis
Preparing for Delivery
• Birthing positions
− Standing birth
• Fetal head is moved away from the sacral area.
− Semi-Fowler’s position
Preparing for Delivery
Preparing for Delivery
• Birthing positions (cont’d)
− Kneeling birth
• Fetal head is moved away from the sacrum.
− Side-lying position
• Fewer perineal tears
Preparing for Delivery
Preparing for Delivery
• Open the OB kit.
• Wash hands.
• Put on gloves.
• Maintain standard
precautions.
• Drape the woman
in sterile towels.
Courtesy of AAOS
Preparing for Delivery
Preparing for Delivery
• A safe and controlled delivery takes
precedence over the draping.
• Have your partner at the woman’s head to
help keep her calm and administer oxygen.
• Encourage the woman to rest between
contractions and to resist bearing down.
Assisting Delivery
• Control delivery.
• Support the head
as it emerges.
• Check for nuchal
cord.
• Clear the airway by
suctioning with a
bulb syringe.
Courtesy of AAOS
Assisting Delivery
Courtesy of AAOS
• Gently guide the
head downward so
the upper shoulder
can deliver.
• Gently guide the
head upward to
allow delivery of
the lower shoulder.
Courtesy of AAOS
Assisting Delivery
• Once delivered,
maintain at the
same level as the
vagina.
• Wipe blood or
mucus from the
newborn’s nose
and mouth with
sterile gauze.
Courtesy of AAOS
Assisting Delivery
• Dry the newborn with sterile towels, and
wrap in a dry blanket.
• Record the time of birth for the PCR.
Assisting Delivery
• Apgar scoring
− Evaluates newborn’s vital functions
• Heart rate
• Respiratory effort
• Muscle tone
• Reflex irritability
• Color
Assisting Delivery
• Cutting the umbilical cord
− Handle the cord with care.
− Tie or clamp the cord with clamps 2 inches
apart, then cut the cord between them.
− Examine the ends to ensure there is no
bleeding.
− Once cut, wrap the newborn in a dry blanket.
Assisting Delivery
• Delivery of the placenta
− Usually within 20 minutes after delivery
− Do not pull on the umbilical cord to speed up
placental delivery.
− Instruct the patient to bear down.
Assisting Delivery
• Delivery of the
placenta (cont’d)
− Fetal side should
be gray, shiny, and
smooth.
− Maternal side
should be dark
maroon with a
rough texture.
© Hattie Young/Photo Researchers, Inc.
Assisting Delivery
• Delivery of the placenta (cont’d)
− Place in a plastic bag, and transport.
− Examine the perineum for lacerations.
− Prepare for transport.
• If the placenta has not delivered after 15 minutes,
begin transport.
Postpartum Care
• Obtain the mother’s vital signs.
• Place a sanitary napkin in front of the
vagina.
• Monitor the mother’s condition closely.
Postpartum Care
• Assess the fundus.
• Note the lochia.
• Cover the mother with blankets.
Emergency Pharmacology in
Pregnancy
• Maternal physiology changes may have an
impact on pharmacologic therapies.
− IV medications may pass quickly through the
maternal system.
− Higher doses may be needed.
− Oral drugs may take longer to work.
Magnesium Sulfate
• In pregnancy, used to manage eclampsia
• Can cause:
− Respiratory depression
− Hypotension
− Circulatory collapse
• Must be administered slowly
Calcium Chloride
• Mainly used to manage hypocalcemia
• Side effects include:
− Nausea and vomiting
− Syncope
− Bradycardia
− Dysrhythmias
Terbutaline
• Administered to suppress preterm labor
• Used to treat pregnancy-induced asthma
• Side effects include:
− Hypertension
− Chest pain
− Cardiac dysrhythmias
Valium
• Indicated in eclampsia when seizures do
not respond to magnesium sulfate
• Principle side effects:
− Nausea and vomiting
− Respiratory depression
− Hypotension
Diphenhydramine
• Used to treat hyperemesis gravidarum.
• Side effects include:
− Drowsiness
− Headache
− Tachycardia
− Hypotension
Oxytocin
• A naturally occurring hormone that causes
uterine contractions and can be used to:
− Induce labor.
− Control postpartum hemorrhage.
Oxytocin
• Side effect include:
− Nausea and vomiting
− Tachycardia
− Seizures
− Cardiac dysrhythmias
Premature Rupture of
Membranes
• The amniotic sac ruptures, or opens, more
than an hour before labor.
− The sac may self-seal and heal itself.
− Often, labor will begin within 48 hours.
• If not near term, a risk of infection exists.
Preterm Labor
• Labor that begins after the 20th week but
before the 37th week
• Patient may be admitted to the hospital for
medication, bed rest, and monitoring.
Fetal Distress
• Caused by many conditions
• Difficult to assess in the field
− Most women will know if fetal movement has
slowed or stopped.
• Provide support and rapid transport.
Uterine Rupture
• Occurs during labor
• Signs and symptoms include:
− Weakness, dizziness, and thirst
− Initial strong contractions that have lessened
− Signs of shock
• Treat for shock, and provide rapid transport.
Precipitous Labor and Birth
• Entire labor time and birth usually occurs in
less than 3 hours.
• Contractions are usually more intense.
• Assess the woman postdelivery for tears
and bleeding.
Postterm Pregnancy
• The fetus has not been born after 42 weeks.
• Cause is unknown.
• High-risk because:
− Fetus may become malnourished.
− Increased chance of meconium aspiration
Meconium Staining
• Meconium: first stool the fetus passes
• May be voided into the amniotic fluid and
cause chemical pneumonia in the newborn.
• Assess for need of suctioning if staining is
present.
Fetal Macrosomia
• Weighs more than 4,500 grams
(almost 9 lb)
• Treatment should focus on:
− Support and rapid transport
− If field delivery:
• Encourage breastfeeding.
• Check newborn’s blood glucose level.
Multiple Gestation
• Prepare for more than one resuscitation.
• Consider the possibility of multiples if:
− First newborn is small
− Abdomen is still fairly large after the birth.
• The second newborn is usually born within
45 minutes.
Multiple Gestation
• The procedure is the same as a single birth.
− Check if there are one or two cords coming out
of the placenta when it delivers.
• Record the time of birth for each newborn.
Intrauterine Fetal Death
• Fetus died in the uterus before labor.
• Care will focus on the woman.
• Actual cause is usually difficult to
determine.
Intrauterine Fetal Death
• Labor can occur up to 2 weeks or more
after the fetal death.
− Labor usually progresses normally.
− Do not attempt resuscitation of an obviously
dead fetus.
Amniotic Fluid Embolism
• Amniotic fluid enters the woman’s
pulmonary and circulatory system through
the placenta.
• Results in an allergic reaction response
• Signs and symptoms include:
− Respiratory distress and hypotension
− Cyanosis
− Possible seizures
Amniotic Fluid Embolism
• If the patient survives the initial reaction,
they will likely develop coagulopathies.
• Treatment includes:
− Supporting respiratory and circulatory systems
− Providing rapid transport
Hydramnios
• Too much amniotic fluid
• Patients are at risk for:
− Prolapsed cord and abruptio placenta
− Postpartum hemorrhage
Cephalopelvic Disproportion
• Head of the fetus is larger than the pelvis.
• A cesarean section is usually required.
Cephalic Presentation
• Newborn’s head is overly extended,
creating a face presentation at birth.
− Brow presentation
− Occiput-posterior presentation
− Military presentation
Cephalic Presentation
• If the newborn’s head cannot be externally
rotated or the delivery cannot be completed:
− Support the woman and fetus.
− Provide rapid delivery.
Breech Presentations
• A different part of
the body besides
the head leads the
way through the
birth canal.
• Types:
− Frank
− Incomplete
− Complete
Breech Presentations
• Position the woman with buttocks at edge of
bed or stretcher, legs flexed.
• Allow newborn’s buttocks and trunk to
deliver spontaneously.
• Once the legs are clear, support the body.
• Lower the newborn slightly.
Breech Presentations
• Once the hairline is spotted, grasp the
newborn’s ankles and lift upward.
• If the head does not deliver within 3
minutes, the newborn may suffocate.
• Do not try to forcibly pull the newborn out.
Breech Presentations
• Other
presentations are
rare.
− Footling breech
− Transverse
presentation
• In abnormal
presentations, do
not attempt
delivery in the field.
Shoulder Dystocia
• Difficulty in delivering the shoulders
• If the shoulders cannot clear the birth canal,
the fetus cannot breathe.
• A major concern once born is brachial nerve
plexus damage.
Shoulder Dystocia
• McRoberts maneuver
− Hyperflex the woman’s legs tightly to the
abdomen.
− May need to apply pressure to the lower
abdomen and gently pull on the fetus’s head.
Nuchal Cord
• The umbilical cord becomes wrapped
around the newborn’s neck during delivery.
− May cause fetal heart rate to slow
• Slip a finder under the cord and gently
attempt to slip it over the shoulder and
head.
− If unsuccessful, cut the cord.
Prolapsed Umbilical Cord
• The cord emerges
before the fetus.
− Shuts off the
oxygenated blood
supply from the
placenta.
− Leads to fetal
asphyxia
Prolapsed Umbilical Cord
• Keep the woman supine with hips elevated.
• Administer 100% supplemental oxygen.
• Have the woman pant with each
contraction.
• Gently push the presenting part back up the
vagina until it no longer presses on the
cord.
Prolapsed Umbilical Cord
• Maintain pressure while another paramedic
covers the exposed cord with dressings.
• Maintain position throughout urgent
transport.
Uterine Inversion
• Placenta fails to detach properly from the
uterine wall when it is expelled.
− Uterus turns inside out as a result.
• Severity graded by how much the uterus
has reversed itself.
• Very painful and may rapidly cause shock.
Uterine Inversion
• Keep the patient recumbent.
• Administer 100% supplemental oxygen.
• Start two IV lines with normal saline.
• Do not attempt to remove placenta if still
attached to the uterus.
Uterine Inversion
• Carefully monitor vital signs.
• Consider oxytocin to control hemorrhage.
• Make one attempt to replace the uterus.
Postpartum Hemorrhage
• Can be either early or late hemorrhage
− Early—bleeding within 24 hours of delivery
− Late—bleeding occurring from 24 hours to 6
weeks after delivery
• Blood loss exceeds 500 mL during first 24
hours after birth.
Postpartum Hemorrhage
• Causes of postpartum hemorrhage include:
− Prolonged labor or multiple baby deliver
− Retained products of conception
− Placenta previa
− Full bladder
Postpartum Hemorrhage
• Continue uterine massage.
• Encourage the woman to breastfeed.
• Notify the receiving facility of status.
• Transport immediately.
• Add a large-bore IV line en route.
Pulmonary Embolism
• Frequently caused by a clot arising in pelvic
circulation from:
− Amniotic embolism
− Pregnancy-related venous thromboembolism
− Water embolism
Pulmonary Embolism
• Suspect if a woman in the postpartum state
experiences:
− Sudden dyspnea
− Tachycardia
−
−
−
−
Atrial fibrillation
Hypotension
Sharp, sudden chest or abdominal pain
Syncope
Postpartum Depression
• May appear up to 1 year after birth
• Signs and symptoms include:
− Signs similar to others with depression
− Anger directed toward the infant
− Little or no interest in the infant
− Thoughts of harming themselves or their infant
Trauma and Pregnancy
• Trauma is a complicating factor in
pregnancy.
• Leading cause of maternal death in United
States
Pathophysiology and
Assessment Considerations
• Anatomic changes are important in trauma.
− Abdominal contents compress into upper
abdomen.
− Diaphragm elevates by about 1.5 inches.
− Peritoneum maximally stretches.
Pathophysiology and
Assessment Considerations
• Pregnant patients will have different signs
or responses to trauma.
− May be more difficult to interpret tachycardia
− Signs of hypovolemia may be hidden.
− Higher chance of bleeding to death in case of
pelvic fractures
− Respiratory rate less than 20 breaths/min is not
adequate.
Considerations for the Fetus
and Trauma
• Fetal injury can occur from:
− Rapid deceleration
− Impaired fetal circulation
• If a pregnant woman has massive bleeding,
maternal circulation will reroute blood from
the fetus.
Considerations for the Fetus
and Trauma
• Fetal heart rate is the best indication of fetal
status after trauma.
− Normal fetal heart rate is between 120 and 160
beats/min.
− Rate slower than 120 beats/min means fetal
distress and a dire emergency.
Management of the Pregnant
Trauma Patient
• Can only treat the
woman directly
− Determine
gestational age of
fetus if possible.
• Transport a
pregnant woman
on left side if no
spinal injury is
suspected.
Management of the Pregnant
Trauma Patient
• Ensure adequate airway.
• Administer oxygen.
• Assist ventilations when needed and
provide a higher-than-usual minute volume.
• Control external bleeding and splint
fractures.
Management of the Pregnant
Trauma Patient
• Start one or two IV lines of normal saline.
• Inform the receiving facility of the patient’s
status and estimated time of arrival.
• Transport the patient in the lateral
recumbent position.
Postpartum Complications
• Maternal cardiac arrest
− Provide CPR and ALS like any other trauma
patient.
− CPR and ventilator support may keep the fetus
viable, even if the mother is already dead.
Summary
• Ovaries are the beginning of reproduction.
During the menstrual cycle, one follicle
releases an ovum which, if fertilized,
develops into an embryo, then a fetus.
• The fallopian tubes transport the ovum from
the ovary to the uterus. Once fertilized, it
implants in the endometrium.
• The fetus is enclosed in the amniotic sac.
Summary
• The gestational period normally lasts 38
weeks.
• In the first trimester, the placenta, umbilical
cord, specialized body systems, and limbs
form. In the second trimester, the fetus
gains weight and body systems become
more specialized. In the third trimester, the
fetus adds weight.
Summary
• Pregnancy is considered at term by week
37 of gestation.
• Physiologic changes during pregnancy can
alter a woman’s response to trauma and
create or exacerbate medical conditions.
• In an obstetric emergency, find out the
length of gestation, estimated due date,
complications with this or other
pregnancies, and if there is any vaginal
bleeding.
Summary
• Potential complications related to
pregnancy include abuse of the pregnant
woman, substance abuse by the pregnant
women, and disorders that can develop
during or be exacerbated by pregnancy.
• Preeclampsia manifests after the 20th
week, with symptoms of edema,
hypertension, protein in the urine, severe
headache, nausea and vomiting, agitation,
rapid weight gain, and visual disturbances.
Summary
• Abortion, or fetal expulsion from any cause
before the 20th week of gestation, can
cause bleeding during pregnancy.
• An incomplete abortion occurs when only
some of the fetal material are expelled.
• Causes of bleeding during pregnancy
include ectopic pregnancy, abruptio
placenta, or placenta previa.
Summary
• Vaginal bleeding may cause shock.
• Labor may begins with a bloody show.
• First stage of labor begins with contraction
onset.
• The second stage begins with the fetus’s
head enters the birth canal.
• The third stage occurs when the placenta is
expelled.
Summary
• When assessing, determine if there is time
to get to the hospital.
• If delivery is imminent, prepare a private,
clean area.
• Never pull on the umbilical cord to deliver
the placenta.
• Pharmacology may include magnesium
sulfate, calcium chloride, terbutaline,
diphenhydramine, and oxytocin.
Summary
• High-risk pregnancy complications include
precipitous labor and birth, postterm
pregnancy, meconium staining, fetal
macrosomia, multiple gestation, intrauterine
fetal death, amniotic fluid embolism,
hydramnios, and cephalopelvic
disproportion.
Summary
• Meconium may be a yellow or greenish
black tint in the amniotic fluid. If the
newborn is depressed and meconium
staining is present, suction the infant.
• Labor complications include premature
rupture of membranes, preterm labor,
uterine rupture, and fetal distress.
• Delivery complications include cephalic
presentation, breech presentation, shoulder
dystocia, nuchal cord, and prolapsed cord.
Summary
• Postpartum complications include uterine
inversion, postpartum hemorrhage,
pulmonary embolism, and postpartum
depression.
• Suspect pulmonary embolism if the
pregnant patient experiences sudden
dyspnea, tachycardia, atrial fibrillation or
hypotension.
Summary
• Treat trauma in a pregnant woman the
same as in a nonpregnant women, except
transport a pregnant patient on her left side
unless a spinal injury is suspected.
Credits
• Chapter opener: © Jones & Bartlett Learning.
Courtesy of MIEMSS.
• Backgrounds: Red—© Margo Harrison/
ShutterStock, Inc.; Green—Courtesy of Rhonda
Beck; Lime—© Photodisc; Purple—Courtesy of
Rhonda Beck.
• Unless otherwise indicated, all photographs and
illustrations are under copyright of Jones & Bartlett
Learning, courtesy of Maryland Institute for
Emergency Medical Services Systems, or have
been provided by the American Academy of
Orthopaedic Surgeons.