Download First, boil water… Obstetrics for Paramedics

First, boil water…
Obstetrics for Paramedics
Rebecca Dunsmoor-Su, MD
Outline
• The basics (anatomy, terminology)
• Normal pregnancy
• Abnormal pregnancy
– First trimester
– Later
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Trauma
Normal labor & delivery
Abnormal labor & delivery
What do you do with the baby?
Anatomy
Anatomy
Terminology
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Gs and Ps
LMP
EDC
Primip
Multip
Precip
Antenatal
Antepartum
Terminology
• Gravidity: Number of times pregnant
• Parity: Number of deliveries (twins only
counts as one)
• Usually expressed as G3P2
• Can also be G3P2012
– P(term, preterm, abortions, living kids)
Terminology
• LMP: Last menstrual period.
Pregnancies are dated from the first day
of the LMP
• EDC: Estimated date of confinement
(EDD: estimated date of delivery)
• For a rough estimate: Add 7 days to 1st
day of LMP, then add 9 months.
(Nagele rule)
Terminology
• Primip: Primipara. Technically,
someone who has had one delivery.
Practically, used interchangably with
primagravida
• Multip: Multipara. Techinically, someone
who has delivered more than one baby.
Practically, anyone who has delivered a
baby.
Terminology
• Precip: Precipitous delivery. One that
happens way too fast - and what you
are most likely to see in your
ambulance! Technically, delivery after
less than 3 hours of labor.
• Antenatal, Antepartum: Before delivery
Normal pregnancy
• Heartbeat visible on
US: 5-6 weeks
• Heartbeat audible with
Doppler: 12 weeks
• Heartbeat audible with
stethoscope: 20
weeks
• Viability: 24 weeks
• Term: 40 weeks (>37
weeks)
Normal pregnancy
• Uterus palpable
above pubic bone
~12 weeks
• Uterus at umbilicus at
20 weeks
• After 20 weeks, cm
measured from
symphysis to fundus
is approx = to GA
Fundal height
Fetal HR 120-150
Physiologic changes
• Respiratory: Progesterone increases
respiratory drive, therefore increased rate,
slightly lower PCO2
• Cardiovascular: Drop in SVR, drop in BP,
increase in pulse. Increased blood volume.
• Renal: Progesterone relaxes ureter,
increasing risk of pyelonephritis
• GI: Progesterone relaxes sphincters, slows
peristalisis: increasing GERD
Physiologic changes
• Hematologic: Increased blood volume,
but less increase in RBCs leads to
relative anemia
• MSK: Progesterone loosens joints,
growing uterus changes center of
gravity
Beware supine hypotension! ALWAYS: Left lateral tilt
Evaluation of a pregnant patient
• ABC’s.
• Mom is first priority,
but always
remember that you
have TWO patients.
• Primary survey is
the same.
Evaluation of a pregnant patient
• Secondary survey:
– Include palpation of uterine fundus
– Listen for fetal heartbeat
– Vaginal bleeding or leaking of fluid?
– Anything protruding from vagina?
– Tender abdomen?
Obstetric HPI
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Gs and Ps
LMP / EDC
Bleeding?
Leaking fluid?
Contracting?
Baby moving?
Medical
Comorbidities?
• Any prenatal care?
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Headache?
Blurry vision?
RUQ pain?
Seizures?
Trauma? Fall?
Any problems with
placenta?
Obstetric History
• POBHx:
– Any C-sections?
– Any surgery on
uterus?
– Any problems with
past pregnancies?
Physical exam
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Pulmonary
Abdominal
Uterus
Fetus
Perineum
DO NOT do an
internal vaginal
exam!
Abnormal pregnancy
First Trimester (0-14 weeks)
Bleeding:
• Up to 20% of pregnancies end in miscarriage
• Vaginal bleeding in the first trimester should ALWAYS
make you think of ectopic pregnancy
• If patient appears sick, consider septic abortion and
ask about medications or instrumentation
• Inevitable vs. Threatened vs. Incomplete
Abnormal pregnancy
First Trimester
uterus
ectopic
• All pregnant women
with bleeding and/or
abdominal pain
have an ectopic until
proven otherwise.
• Bleeding ectopic is a
true OB/Gyn
emergency and
needs to get to an
OR
Abnormal pregnancy
after 20 weeks
Bleeding:
Medical:
• Placenta previa
• Pre-eclampsia
• Placental abruption
• Eclampsia
• Preterm labor
• Diabetes
• PPROM
Placenta previa
Painless vaginal bleeding
Associated with placenta
accreta (placenta growing
into uterine wall)
ANY bleeding is a bad
sign, proceed with haste.
Placental abruption
Painful vaginal bleeding
Signs:
Bleeding, contractions,
abdominal tenderness,
pain
Risk factors:
Cocaine, Trauma, HTN,
PPROM, Smoking,
Multiparity
Preterm labor
• Technically, labor prior to 37
weeks. Practically, no
treatment to stop contractions
if >34 weeks.
• Difficult diagnosis in the field,
since labor implies cervical
change.
• Err on the side of caution
and presume any abdominal
or back pain is contractions.
• Many causes
PPROM
Preterm Premature Rupture of Membranes
Sometimes hard to
diagnose
Often caused by infection
Associated with increased
risk of abruption, cord
prolapse, cerebral palsy
(when accompanied by
infection)
Pre-eclampsia
• Blood pressure >140/90
• Proteinuria >1+ (300mg/24h)
• Symptoms:
• Headache
• Blurry vision
• RUQ pain
• Edema
• Signs:
• Hyperreflexia
• Pulmonary edema
• Oliguria
Pre-eclampsia
•
Associated with:
• Seizures (eclampsia)
• Stroke
• HELLP:
• Hemolysis
• Elevated Liver enzymes
• Low Platelets
• Abruption
Key treatment:
Magnesium sulfate
and/or delivery
Diabetes
• Placenta makes a hormone, HPL, that creates insulin
resistance.
• Pre-existing diabetes is worsened by pregnancy
• Some women develop gestational diabetes (like Type 2)
and may be on insulin (so think about hypoglycemia)
• DKA can develop more quickly and at lower blood sugar
than in non-pregnant women
Trauma
• Number one cause of non-obstetric maternal death
• Treat mom first
• Volume, volume, volume (be careful)
• Remember left lateral tilt
• Fetal survival drops dramatically 15 minutes after a
maternal arrest, but 90% will survive if C-section done
prior to 15 minutes.
• All but the most minor trauma over 24 weeks will have
at least 4 hours of uterine monitoring to evaluate for
abruption. (After 20 weeks - 5 months - ideal to
transport everyone for evaluation)
Normal labor and delivery
What do we mean by labor?
3 stages of labor
Stage 1: 0-10 cm dilation
(Active phase after 34cm)
Stage 2: 10cm to delivery
Stage 3: delivery of baby to
delivery of placenta
Delivery
• Don’t panic.
• Control the infant head
• Support maternal perineum
• Once head is out, sweep for
nuchal cord
• Gentle downward traction,
then gentle upward traction
• Support fetal body
Nuchal cord
Third stage
• Signs of placental separation:
• Gush of blood
• Lengthening of cord
• Avoid heavy traction on the cord
• Monitor for increased bleeding
• Fundal massage
• Pitocin (20 units in 1 litre) - can start this as soon as
the baby is out.
Abnormal labor and delivery
• Prolapsed cord
• Cephalopelvic
disproportion
• Shoulder dystocia
• Breech presentation
• Limb presentation
• Meconium
• Uterine rupture
• Post-partum
hemorrhage
• Uterine inversion
• Amniotic fluid
embolus
• Pulmonary embolus
Prolapsed Cord
• OB emergency:
essentially cuts off all
oxygen to fetus
• Cesarean delivery STAT
• In field: hand in vagina,
elevate fetal head off the
cord.
• Elevate hips: knee to
chest or Trendeleberg
Cephalopelvic disproportion
Prolonged labor
• Minimal expected cervical
change is ~1cm/hr in active
phase.
• Slower rate can indicate
malposition, large baby,
inadequate contractions
Shoulder dystocia
Anterior shoulder stuck behind
pubic symphysis
Signs:
• Shoulder does not deliver easily
with next contraction
• Head retracts “turtle sign”
McRoberts maneuver: Knees to
ears!
This is like a code: document,
document, document
Abnormal presentation
Breech
Footling breech
Limb presentation
Risks:
Head entrapment
Cord prolapse
Breech delivery
Allow progress of labor and pushing to deliver baby past
hips
Support the infant body, and wrap it in a towel
Grasp infant at hips, with thumbs on sacral alae
Pull gently down until you see the scapula
Reach up and sweep down each arm
Put fingers on maxillae to flex head and/or provide
space for baby to breathe
Meconium
• Theory is that it indicates
baby under stress
• Previously all babies with
meconium had deep
suction prior to delivery of
shoulders.
• Now, only those with poor
respiratory effort or sats
should be intubated and
suctioned.
• Suction mouth and nose
on perineum and be
prepared.
Uterine rupture
Signs:
• Vaginal bleeding
• 0.5-1% risk in women with
one prior C-section
• Loss of fetal station
• 5-50% risk of fetal death
• Abdominal pain
• Risk of maternal hemorrhage
• Acute abdomen
• Fetal distress
• Maternal shock
Post-partum hemorrhage
• >500cc after vaginal delivery
• Can be a sign of uterine atony,
retained placenta, placenta acreta
•Rx:
• Fundal massage
• Empty bladder
• Pitocin (20-40units in 1L NS)
• Misoprostol 600-800mcg per rectum
• Hemabate / methergine
Uterine Inversion
Try to gently
push it back in.
Do not remove
placenta!
Proceed with
haste to an OB
Emboli
Amniotic fluid or blood clot
Present as sudden hypoxia,
dyspnea, cardiovascular
compromise
Treat as any patient in shock,
pulmonary arrest or with
severe hypotension
What do I do with the baby?
Airway &
Breathing
Tone &
Reflexes
Circulation
& Color
Dry the baby and keep her warm: skin to skin is best
APGAR Score
Appearance:
Grimace:
Respiration
0 = blue or white
0 = No response
0 = Absent
1 = pink body, blue extrem.
1 = grimace
2 = pink
2 = Cries
1 = Slow or
irregular
2 = Strong cry
Pulse
0 = absent
1 = <100
2 = >100
Activity
0 = limp
1 = Some flexion
2 = Active movement
Neonatal resuscitation
A: Airway: Is it clear of meconium?
Is the head properly positioned?
B: Breathing: Is there respiratory effort?
Is the baby pink?
C: Circulation: Is there a pulse in the umbilical cord?
Is the heart rate >100?
Neonatal resuscitation
Poor color
Blow-by O2
Stimulation
Evaluate respirations,
heart rate and color
Apnea
HR <100
HR <60
Positive-pressure
ventilation
HR <60
Chest
compressions
Consider intubation
Epi
Questions?