Chapter 42
Obstetrics
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42-1
Objectives
42-2
Anatomy and Physiology Review
42-3
Female Anatomy and Physiology
4
[Insert figure 42-1]
42-4
Female Anatomy and Physiology
• Vagina
– Birth canal
[Insert figure 42-2]
• Perineum
– Area between
vaginal opening
and anus
42-5
Structures of Pregnancy
42-6
Female Anatomy and Physiology
[Insert figure 42-3]
42-7
Female Anatomy and Physiology
[Insert figure 42-4]
42-8
Normal Pregnancy
42-9
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
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
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
Third Trimester
• Months 7 to 9
– Stretch marks
may appear
[Insert figure 42-5]
42-13
Assessing the Pregnant Patient
42-14
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
SAMPLE History
Signs and symptoms that may indicate a
possible complication of pregnancy:
•
•
•
•
•
•
•
•
Seizures
• Passage of clots or
tissue
Weakness
• Swelling of face
Dizziness
and/or extremities
Faintness
• Abdominal
Signs of shock
cramping or pain
Lightheadedness
Vaginal bleeding
Altered mental status
42-16
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
Physical Examination
• The vaginal area is touched only during
delivery and (ideally) when another
healthcare professional or law
enforcement officer is present
42-18
Normal Labor
42-19
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
Stages of Labor
[Insert figure 42-11A]
42-21
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
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
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
True and False Labor Contractions
True Labor Contractions
• Occur regularly
• Get closer together
False Labor Contractions
• Are usually weak,
irregular
• Become stronger as
time passes
• Do not get closer
together over time
– Each lasts about 30 to 60
seconds
• Continue despite the
patient’s activity
• Do not get stronger
• May stop or slow down
when the patient walks,
lies down, or changes
position
42-25
Normal Delivery
42-26
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
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
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
Crowning
[Insert figure 42-12]
42-30
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
OB Kit
[Insert figure 42-13]
42-32
Preparing for Delivery
Insert figure 42-14
42-33
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
Delivery Procedure
42-35
Delivery Procedure
42-36
Delivery Procedure
[Insert figure 42-16]
42-37
Delivery Procedure
[Insert figure 42-17]
42-38
Delivery Procedure
[Insert figure 42-18]
42-39
42-40
Delivery Procedure
[Insert figure 42-22]
42-41
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
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
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
Caring for the Mother
42-45
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
Complications of Pregnancy
42-47
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
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
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
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
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
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
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
Substance Abuse
• Cocaine
– Early pregnancy
• Increased risk of miscarriage
– Later in pregnancy
• Preterm labor
• Placental problems, including placental
abruption
42-55
Diabetes and Pregnancy
• Pregestational diabetes
• Gestational diabetes
42-56
Diabetes and Pregnancy
• Increased risk
– Premature birth
– Birth defects
– Very large baby
42-57
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
Abortion
• Spontaneous abortion
– Miscarriage
– Loss of fetus because of natural causes
before the 20th week of pregnancy
42-59
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
Ectopic Pregnancy
42-61
Ectopic Pregnancy
[Insert figure 42-6]
42-62
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
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
Placental Problems
42-65
Placenta Previa
[Insert figure 42-7 A, B]
42-66
Abruptio Placentae
• Occurs when a normally implanted placenta
separates prematurely from the wall of the
uterus
– Placenta may separate partially or
completely
42-67
Abruptio Placentae
[Insert figure 42-8A]
42-68
Abruptio Placentae
[Insert figure 42-8B]
42-69
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
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
Hypertensive Disorders
42-72
Preeclampsia
• Condition of high blood pressure and
swelling during pregnancy
– Usually occurs during the third trimester
42-73
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
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
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
Patient Positioning
42-77
High-Risk Pregnancy
42-78
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
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
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
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
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
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
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
Intrauterine Fetal Death
• Most fetal deaths occur:
– Before 32 weeks gestation
– Before the onset of labor
42-86
Complications of Labor
42-87
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
Preterm Labor
• Labor that begins before the 37th week of
gestation
• May result in premature delivery of the infant
• Transport
42-89
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
Complications of Delivery
42-91
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
Breech Presentation
42-93
Breech Birth
42-94
Prolapsed Cord
42-95
Prolapsed Cord
42-96
Postpartum Complications
42-97
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
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
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
42-100
indicated
Questions?
42-101