1. Copyright (c) The McGraw-Hill Companies, Inc. Permission required for reproduction or display. 42-1 Chapter 42 Obstetrics

2. 42-2 Objectives

3. Anatomy and Physiology Review 42-3

4. [Insert figure 42-1] Female Anatomy and Physiology 4 42-4

5. Female Anatomy and Physiology Vagina –Birth canal Perineum –Area between vaginal opening and anus 42-5 [Insert figure 42-2]

6. Structures of Pregnancy 42-6

7. Female Anatomy and Physiology [Insert figure 42-3] 42-7

8. [Insert figure 42-4] Female Anatomy and Physiology 42-8

9. Normal Pregnancy 42-9

10. First Trimester Months 1 to 3 (weeks 1 – 12) –Missed period –Swollen and tender breasts –Frequent urination –Sleeping more than usual –Morning sickness –Heart rate increases by 10 to 15 beats/minute 42-10

11. Second Trimester Months 4 to 6 (weeks 13 – 27) –Signs of pregnancy are more obvious –Abdomen enlarges –May walk and move about differently –Begins to feel the fetus move at about the 4th or 5th month –Blood pressure (BP) Systolic BP may drop 5 to 10 points Diastolic BP may drop 10 to 15 points 42-11

12. Third Trimester Months 7 to 9 (weeks 28 – 40) –May complain of a backache due to muscle strain –Frequent urination Weight of uterus presses on bladder –May be short of breath Uterus expands beneath the diaphragm 42-12

13. Third Trimester Months 7 to 9 –Stretch marks may appear 42-13 [Insert figure 42-5]

14. Assessing the Pregnant Patient 42-14

15. Assessment Remember that vital signs change with pregnancy –Heart rate Normally slightly faster than usual –Breathing rate Slightly faster More shallow than normal –Blood pressure Slightly lower than normal until the third trimester 42-15

16. SAMPLE History Signs and symptoms that may indicate a possible complication of pregnancy: Seizures Weakness Dizziness Faintness Signs of shock Lightheadedness Vaginal bleeding Altered mental status Passage of clots or tissue Swelling of face and/or extremities Abdominal cramping or pain 42-16

17. Physical Examination Preserve the patient’s modesty Do not visually inspect the vaginal area unless: –Major bleeding is present –You anticipate that childbirth is about to occur Have another healthcare professional or law enforcement officer present 42-17

18. Physical Examination The vaginal area is touched only during delivery and (ideally) when another healthcare professional or law enforcement officer is present 42-18

19. Normal Labor 42-19

20. Labor and Delivery Labor –Uterus contracts to push the fetus and placenta out of the mother’s body –Begins with the first uterine muscle contraction –Ends with delivery of the placenta Delivery –Birth of the baby at the end of the second stage of labor 42-20

21. Stages of Labor 42-21 [Insert figure 42-11A]

22. First Stage of Labor Begins with the first contraction Ends with complete thinning and opening of the cervix Contractions –Gradually increase in strength –Usually last 30 to 60 seconds –Occur every 5 to 15 minutes 42-22

23. Second Stage of Labor Begins with the opening of the cervix Ends with delivery of the infant Contractions –Stronger –Last 45 to 60 seconds –Occur every 2 to 3 minutes 42-23

24. Third Stage of Labor Begins with delivery of the infant Ends with delivery of the placenta Lasts about 5 minutes to 1 hour 42-24

25. True and False Labor Contractions True Labor Contractions Occur regularly Get closer together Become stronger as time passes –Each lasts about 30 to 60 seconds Continue despite the patient’s activity False Labor Contractions Are usually weak, irregular Do not get closer together over time Do not get stronger May stop or slow down when the patient walks, lies down, or changes position 42-25

26. Normal Delivery 42-26

27. Where to Deliver the Baby? Is this your first pregnancy? When is your due date? Has your bag of waters broken? –When? What was the color of the water? Any vaginal bleeding or discharge? –How long ago? Any pain with the bleeding? Are you having contractions? –When did they start? How close are they now? Do you feel the need to push or bear down? How many babies are there? 42-27

28. Important Questions Have you taken any medications or drugs? Has your doctor told you if the baby is coming head first or feet first? 42-28

29. Signs of Imminent Delivery Consider delivering at the scene when: –Delivery can be expected in a few minutes –A woman in late pregnancy feels the urge to push, bear down, or have a bowel movement –Crowning is present –Contractions are regular, last 45-60 seconds, and are 1-2 minutes apart –No suitable transportation is available –Hospital cannot be reached because of heavy traffic, bad weather, a natural disaster, or a similar situation 42-29

30. Crowning 42-30 [Insert figure 42-12]

31. Preparing for Delivery Although you may be nervous: –Appear calm and confident –Reassure the mother-to-be that you won’t leave her alone –Coach her through labor with words of support –Repeat instructions as often as needed 42-31

32. OB Kit 42-32 [Insert figure 42-13]

33. Preparing for Delivery 42-33 Insert figure 42-14

34. Preparing for Delivery Do not let the mother go to the bathroom Do not hold the mother’s legs together Do not attempt to delay or restrain delivery in any way 42-34

35. Delivery Procedure 42-35

36. Delivery Procedure 42-36

37. Delivery Procedure 42-37 [Insert figure 42-16]

38. Delivery Procedure 42-38 [Insert figure 42-17]

39. Delivery Procedure 42-39 [Insert figure 42-18]

40. 42-40

41. Delivery Procedure 42-41 [Insert figure 42-22]

42. Caring for the Mother Signs of placental separation: –A gush of blood –Lengthening of the umbilical cord –Contraction of the uterus –An urge to push 42-42

43. Caring for the Mother After delivery of the placenta: –Check the mother’s perineum for bleeding –Use a sanitary pad to apply pressure to any bleeding tears –Do not touch the side of the pad that will be placed against the patient –Do not place anything inside the vagina 42-43

44. Caring for the Mother Normal blood loss during childbirth –Up to 500 mL (½ L) Place a sanitary pad over the vaginal opening Reassess the mother to be sure she does not lose too much blood 42-44

45. Caring for the Mother 42-45

46. Caring for the Mother En route to the hospital: –Take patient’s vital signs often –Assist the mother to a position of comfort –Keep her warm –Recheck the amount of vaginal bleeding –Replace sanitary pads as needed –Replace soiled sheets and blankets with fresh ones –Carefully place all soiled items in a biohazard container 42-46

47. Complications of Pregnancy 42-47

48. Abuse Intimate partner violence can lead to: –Blunt trauma to the abdomen –Hemorrhage (including placental separation) –Uterine rupture –Miscarriage/stillbirth –Preterm labor –Premature rupture of the membranes –Premature delivery –Death of the mother 42-48

49. Abuse 77% of pregnant homicide victims are killed during their first trimester of pregnancy Homicide is a leading cause of traumatic death among new and expectant mothers Most maternal homicides caused by gunfire; stabbings ranked second. 42-49

50. Abuse Be aware of possible warning signs of possible intimate partner violence. Know the mandatory reporting laws in your state. Behaviors of an abused woman Behaviors of the abuser 42-50

51. Abuse Ask questions away from partner, family, and friends Reasons for not disclosing violence: –Embarrassment and shame –Fear of retaliation by the violent partner –Lack of trust in others –Economic dependence, –Desire to keep the family together –Lack of awareness of alternatives –Lack of a support system 42-51

52. Abuse Accurate documentation is essential. Whenever possible, use the patient’s own words to describe the violence. Be certain to privately relay your findings when transferring patient care. 42-52

53. Substance Abuse Smoking –Increases risk of stillbirth or premature birth Alcohol –The amount of alcohol that a woman can “safely” drink during pregnancy is not known. –Fetal alcohol syndrome –Alcohol-related neurodevelopmental disorder 42-53

54. Substance Abuse Methamphetamine –Increased risk of premature delivery and placental problems –Infants undergo withdrawal-like symptoms Heroin –Poor fetal growth, premature rupture of the membranes, premature delivery, and stillbirth –Infants go through withdrawal 42-54

55. Substance Abuse Cocaine –Early pregnancy Increased risk of miscarriage –Later in pregnancy Preterm labor Placental problems, including placental abruption 42-55

56. Diabetes and Pregnancy Pregestational diabetes Gestational diabetes 42-56

57. Diabetes and Pregnancy Increased risk –Premature birth –Birth defects –Very large baby 42-57

58. Abortion Termination of pregnancy before the fetus is able to live on its own outside the uterus –Therapeutic abortion An abortion performed for medical reasons, often because the pregnancy poses a threat to the mother’s health –Elective abortion Abortion performed at request of the mother 42-58

59. Abortion Spontaneous abortion –Miscarriage –Loss of fetus because of natural causes before the 20th week of pregnancy 42-59

60. Emergency Care Administer oxygen Assess and treat for shock Keep the patient warm Collect tissue passed from the vagina –Use biohazard bag or appropriate container with a lid –Collected tissue to accompany patient to the hospital Provide emotional support 42-60

61. Ectopic Pregnancy 42-61

62. Ectopic Pregnancy 42-62 [Insert figure 42-6]

63. Ectopic Pregnancy If rupture occurs: –Patient may experience sudden, severe pain on one side of the lower abdomen –Vaginal bleeding may or may not be present –Patient may feel faint or actually faint –Patient may complain of severe pain in the back of the shoulder (referred pain) –Patient may have severe internal bleeding –Patient may exhibit signs of shock 42-63

64. Emergency Care Medical emergency! Prepare for immediate transport Keep on scene time to a minimum Give oxygen by nonrebreather mask Assess and treat for shock Keep the patient warm Provide emotional support for the patient and family 42-64

65. Placental Problems 42-65

66. Placenta Previa 42-66 [Insert figure 42-7 A, B]

67. Abruptio Placentae Occurs when a normally implanted placenta separates prematurely from the wall of the uterus –Placenta may separate partially or completely 42-67

68. Abruptio Placentae 42-68 [Insert figure 42-8A]

69. Abruptio Placentae 42-69 [Insert figure 42-8B]

70. Uterine Rupture Tearing (rupture) of the uterus Possible causes: –Strong labor for a long period Most common cause –Abdominal trauma Severe fall Sudden stop in a motor vehicle collision 42-70

71. Emergency Care of Vaginal Bleeding Keep on scene time to a minimum Request ALS personnel as soon as possible Standard precautions Give oxygen Treat for shock Keep the patient warm Monitor vital signs every 5 minutes 42-71

72. Hypertensive Disorders 42-72

73. Preeclampsia Condition of high blood pressure and swelling during pregnancy –Usually occurs during the third trimester 42-73

74. Preeclampsia Signs and Symptoms Weight gain of more than 2 pounds per week or sudden weight gain over 1 to 2 days Visual disturbances Swelling of the face and hands on arising from sleep Headaches Right upper quadrant abdominal pain Increased blood pressure 42-74

75. Eclampsia Seizure phase of preeclampsia Keep on scene time to a minimum Have suction readily available Give oxygen Keep the patient calm Position the patient on her left side Avoid stimuli that might trigger a seizure Transport without lights / siren 42-75

76. Care of Pregnancy Complications PPE is important! Keep on scene time to a minimum Give oxygen Treat for shock if indicated If vaginal bleeding is present, apply external vaginal pads as necessary Keep the patient warm Monitor vital signs every 5 minutes 42-76

77. Patient Positioning 42-77

78. High-Risk Pregnancy 42-78

79. Precipitous Labor and Birth Precipitous labor lasts less than 3 hours from the start of contractions to delivery. It occurs more often in a woman who has previously delivered a child than in a woman who is pregnant for the first time. Precipitous labor can result in lacerations of the cervix and vagina, hemorrhage, and fetal distress. 42-79

80. Postterm Pregnancy Post-term pregnancy –Also called prolonged pregnancy –Pregnancy that lasts longer than 42 weeks Postmaturity –The fetus or newborn resulting from a prolonged pregnancy 42-80

81. Postterm Pregnancy Amniotic fluid volume decreases –Increased risk that the fetus will entrap or compress umbilical cord Likelihood of meconium passage into the amniotic fluid increases 42-81

82. Postterm Pregnancy Risks to the mother –Prolonged labor –Injury to the perineum Psychological effects –May be irritable, impatient, and frustrated Provide emotional support Reassess as often as indicated 42-82

83. Meconium Staining Passage of fetal stool into the amniotic fluid –Color varies from yellow, light green, or dark green (pea soup) Seen most often in postterm deliveries Suction the baby’s mouth and nose as soon as the head is delivered 42-83

84. Multiple Gestation Anticipate multiple births if: –Mother’s abdomen appears unusually large –Mother’s abdomen remains large after the first infant is delivered –Contractions continue after delivery of the first infant 42-84

85. Multiple Gestation Request ALS personnel early Steps for delivery and newborn care are the same as with the delivery of one baby Clamp or tie umbilical cord after first baby is born, then cut cord Note times of birth for each baby Clearly label / identify each baby 42-85

86. Intrauterine Fetal Death Most fetal deaths occur: –Before 32 weeks gestation –Before the onset of labor 42-86

87. Complications of Labor 42-87

88. Premature Rupture of Membranes Rupture of the amniotic sac before the onset of labor Increased risk of fetal infection Transport for physician evaluation 42-88

89. Preterm Labor Labor that begins before the 37 th week of gestation May result in premature delivery of the infant Transport 42-89

90. Premature Birth Keep the infant warm Keep the mouth and nose clear of fluid and mucus Give blow-by oxygen Prevent bleeding from the umbilical cord Protect the infant from contamination Reassess 42-90

91. Complications of Delivery 42-91

92. Abnormal Presentations Presenting part –Back of the fetal head (occiput) Occiput posterior presentation –Chin Face presentation –Brow Brow presentation –Head and one or more extremities Compound presentation 42-92

93. Breech Presentation 42-93

94. Breech Birth 42-94

95. Prolapsed Cord 42-95

96. Prolapsed Cord 42-96

97. Postpartum Complications 42-97

98. Postpartum Hemorrhage Hemorrhage greater than 500 mL following delivery Most common complication of labor and delivery Most likely to occur during the first hour after delivery of the placenta Immediate postpartum hemorrhage –Occurs within the first 24 hours of delivery Delayed postpartum hemorrhage –Occurs 24 hours to 6 weeks after delivery 42-98

99. Postpartum Hemorrhage Administer high flow oxygen Supine position Keep patient warm Place infant at mother’s breast If uterus feels soft, perform uterine massage Do not attempt to force delivery of the placenta Do not pack the vagina Consult with medical direction 42-99

100. Amniotic Fluid Embolism Rare complication of labor and delivery Sudden onset of dyspnea and tachycardia –Severe hypotension, severe hypoxia, and loss of consciousness –Heavy uterine bleeding may be present –Respiratory arrest and cardiac arrest soon follow Consult with medical direction –Give oxygen –Perform cardiopulmonary resuscitation if indicated 42-100

101. Questions? 42-101