EMS OBGYN
OVERVIEW
LYSTRA WILSON-CELESTINE, FACOG
May 21th 2015
OBJECTIVES
 Review female anatomy and reproductive system
 Normal pregnancy, labor and delivery
 Assessing a pregnant patient
 Common complications and emergencies of
pregnancy
 Newborn care
 Review of case scenarios
Definition of Terms
 Gravity: # of pregnancies
 Parity: # of pregnancies >20wk
 Nulliparous: never pregnant
 Primagravid: first pregnancy
Definition of Terms
 Presentation: leading part in birth canalcrown, rump, face, arm.
 Term : 37 to 42wks.
 Preterm : <37wks
 Post term:>42wks
 Abortus: Fetus /embryo delivered
<20wk/500gm
External Genitalia
Pelvic Anatomy
Reproductive Organs
Physiology of Pregnancy
 Genital Tract
 Vagina, perineum:
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Increased vascularity, hyperemia, edema
Increased secretions (thick white discharge)
Acidic pH( 3.5-6)
Increased vaginal wall length
Chadwick’s sign- violet color of vagina/vulva
Normal cervix
Chadwick’s sign and leucorrhea
Chadwick sign- pregnant
Physiology of Pregnancy
Uterus
 500-1000 fold increase in size
 Wt. at term +/- 1100gm
 Out of pelvis by end of 12th wk.
 Dextrorotated
 Blood flow increases from 100 to 650ml/min
 Limited auto regulation
Physiology of Pregnancy
Uterus
 Limited Auto regulation
 Maximum uterine vessel dilation leave little auto regulation to
improve flow during perfusion pressure changes
 Decreased maternal cardiac output blood flow shift away
from placenta to maternal brain, kidney and heart.
 Uterine Hypertrophy
 Venous compression fall in venous return, fall in cardiac
output
 Compensation: Supine hypotension syndrome, nausea,
dizziness, syncope, relief by position change
Physiology of Pregnancy
Cervix
 Thickened mucus
 Chadwick sign
 Eversion of columnar cervical glands
Physiology of Pregnancy
Ovaries
 Suspended follicular maturation
 Enlarged ovarian veins
 Single corpus luteum
 Functional 4-5wks post ovulation
 Produces progesterone, relaxin
Physiology of Pregnancy
Skin
 Vascular
 Spider angiomas
 Palmar erythema- also seen thyroid disease, lung CA
or inherited
 Striae gravidarum
 Genetic disposition
Palmar erythema
Spider Angioma
Striae gravidarum
Physiology of Pregnancy
Skin
 Increased pigmentations due to estrogen,
progesterone, melanocytes simulating hormones
 Linea negra
 Chloasma/Melasma gravidarum
Linear Negra
Molasma Gravidarum
Physiology of Pregnancy
Breast
 Tender/tingling sensation in early preg
 Nipple enlarges, broader areolae with increased
pigmentation
 Increase size from ductal growth and alveolar
hyperplasia
 Colostrum production
Physiology of Pregnancy
Musculoskeletal
 Lumbra lordosis low back pain
 Relaxation of pubic symphysis and sacroiliac joints
 Relaxed muscles leading to hernia and easily
strained muscles
 All compounded by weight gain.
Lordosis of pregnancy
Physiology of Pregnancy
Hematologic
 50% increases in blood volume
 Plasma volume increases 50-70%; starts at
6wks
 RBC mass increase 20-35%: starts at 12wk
 Physiologic anemia
 Hemodilutional
 Anemia nadirs at 30-34wks
Physiology of Pregnancy
Hematology
 Iron Deficiency Anemia
 Increased iron requirements, supplements
recommended
 term Hgb <10mg/dL due to deficiency rather than
hemodilution
 Immune changes
 WBC increases to 6000-16000 in 3rd TM
 Plt decrease slightly
Physiology of Pregnancy
Hematology
 Coagulation
 Fibrinogen increases 50%
 Changes in clotting factors and regulatory protein
 Cardiac output
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Begins to increase by 5th wk
Peaks at 20-24wks
Rises by 40% by 20-24wks
Overall 50% increase
Physiology of Pregnancy
Hematology
 Initially increase in heart rate
 Reduced systemic vascular resistance
 CXR: displaced heart to left upward and pericardial
effusion
Physiology of Pregnancy
Test Interpretation
 BP: SBP increases by 5-10mmHg; DBP by 1015mmHg (before 24wks).
 Each contraction pushes 300-500ml from uterus to
circulation Rise in arterial BP 10mmHg during Ctx.
Physiology of Pregnancy
Respiratory
 Estrogen hyperemic, edematous nasopharynx and
increased mucous secretions. Symptoms: stuffiness,
epistaxis, chronic cold.
  chest circum. and transverse diameter; Diaphragm
pushed up 4cm Changes in lung volumes and
pulmonary function test.
 Oxygen consumption increases 15-20%
 BOTTOM LINE
State of hyperventilation with chronic respiratory
alkalosis
Physiology of Pregnancy
Urinary
• Mechanical
 Ureteric obstruction from uterus
 Incomplete bladder empting
 Vesicoureteral reflux
• Physiology
 75%  renal blood flow with increase in GFR 50%
 Multiple trips to bathroom
 Glucosuria, Proteinuria
Physiology of Pregnancy
Gastrointestinal
 Increased appetite (300kcal/d)
 Ptyalism (1-2L/d) spitting
 Gingivitis
 Lower tone of Gastroesophageal sphincterreflux
 Delay gastric emptying (60% of meal emptied in
90mins for non-pregnant; doubled time for
pregnant)
Physiology of Pregnancy
Gastrointestinal
 Increased small bowel transit time 58 vs 52hrs
 Stomach and intestinal displacement appendix at
right flank
 Constipation/Hemorrhoids
 Gallbladder changes increased risk of stones
Normal Pregnancy Events
 1st Trimester (LMP to 13wks)
 Nausea/Vomiting, fatigue, Food aversion or cravings,
spotting, breast tenderness, increased sex drive
 Gain about 5-8lbs
 Complications- Miscarriage, Ectopic, blighted ovum
Normal Pregnancy Events
• 2nd Trimester (13-26wks)
 Feeling of well being, less fatigue.
 Round ligament pain, bladder pressure, round ligament
pain, Braxton hicks
 Complications- fetal loss is minimal but can seen with
labor, incompetent cervix, intrauterine death.
Normal Pregnancy Events
• 3rd Trimester (26wks to delivery)
 Feeling uncomfortable; pelvic/back pain and pressure
 Lower extremities swelling, varicosities, engagement,
contractions,.
 Wt gain 1lbs/wk
 Complications: Rupture membranes, preterm labor,
pregnancy induced hypertension, Urinary tract
infection, Gestational diabetes
Complications of
Pregnancy
 Vaginal bleeding
 Spontaneous Miscarriage
 Ectopic Pregnancy
 Premature rupture of membranes with cord
prolapse
 Pre eclampsia/Eclampsia
 Placental Previa
Complications of
Pregnancy
 Medical/surgical eg diabetes, ruptured appendix
 Abruptio Placenta
 Breech presentation and delivery
 Meconium Stained fluid
 Abnormal labor pattern
 Stressed Newborn
Labor
 Clinical diagnosis
 Onset of regular rhythmic contractions
 Progressive cervical dilation and effacement
 3 stages
Stages of Labor
 Stage 1
 Interval between labor onset and full cervical dilation
 Latent phase- period btw labor onset to start of rapid
change of cervical dilation
 Active phase- period from 6cm to 10cm
Stages of Labor
 Stage 2
 Interval btw full dilation (10cm) to delivery of infant
 Nulliparous- push for max of 2hr without regional
anesthesia(3hr with)
 Multiparous- push for max 1hr without anesthesia (2hr
with)
Stages of Labor
 Stage 3
 Refers to delivery of placenta and fetal membranes
 Make take up to 30mins
 What are the active interventions if >30mins?
Cardinal Movement
of Labor
 Engagement- passage to widest diameter of
presenting part below plan of pelvic inlet
 Descent- downward passage of presenting part
through pelvis
 Flexion- passive flexion of head on to chest
Cardinal Movements
of Labor
 Internal Rotation- vertex moves from transverse to
anteroposterior position
 Extension – fetus head is at level of introitus; base of
occiput is at inferior margin of pubic symphysis
 External Rotation- or restitution- return of head to
correct anatomical position- LOA or ROA
 Explusion- delivery of rest of fetus
Demonstration of Delivery
Method.
 https://www.youtube.com/watch?v=ZDP_ewMD
xCo
Field Obstetric Assessment
 Determine if delivery is imminent
 Remain calm
 Ask few questions
 Closed ended
 Simple answers
 Perform visual exam (with permission)
 Evaluate vitals
Obstetrics Assessment
 Things you want to know
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Due date
Number of pregnancies delivered in past
Length of labor in past
Is there vaginal bleeding or did she break her water
Is there a feelings to have a bowel movement
Obstetrics Assessment
 If delivery is imminent- What are the signs?
 Crowning or bulging
 She screams “I need to take a dump “or “its coming”
or “I have to push”
 What to do!
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Remain calm, place patient supine in safe location.
Disrobe undergarment – have pt/husband/ SO do it.
Visual check of perineum- blood loss, fetal parts, bag
Abdominal palpation for contractions-duration,
interval
Obstetrics Assessment
Field Delivery
 Anticipate exposure of large amount of blood and
body fluids
 Full personal protection is recommended
 Don’t assume absence or presence of disease by
appearance of patient or situation.
Sterile OB Kit Content
 Sterile exam gloves
 Disposable bulb syringe
 Disposable scalpel
 Disposable plastic apron
 Maternity pad
 Plastic bag to hold placenta
 Plastic lined under pad
 Twist ties
 Receiving blanket
 O.B. towelettes
 Disposable towels
 Umbilical cord clamp
 Gauze sponges
Obstetrics Assessment
Field Delivery
 You are ready for a delivery!!!
Crowning/Extension
External Rotation
External Rotation
Delivery of Anterior
Shoulder
Delivery of Posterior
Shoulder
Double cord clamping and
cutting
Case Scenario #1
Case Scenario #1
 Post partum hemorrhage risk factors:
 Grand multiparous, rapid labor, prolonged labor,
augmented labor
 History of postpartum hemorrhage, episiotomy,
especially mediolateral, preeclampsia,
 Overdistended uterus (macrosomia, twins,
hydramnios), operative delivery, Asian or Hispanic
ethnicity, chorioamnionitis
Case Scenario #2
Case Scenario #2
 Cord Prolapse
 True emergency
 Need to release pressure of head against cord
 Sterile vaginal exam check for cord pulsation and
push up on vertex.
 Keep hand in vagina until OB team takes over.
 Emergency cesarean section with general anesthesia is
fastest way to deliver.
Case Scenario #2
Case Scenario #3
Case Scenario #3
 Abruptio Placenta
 Premature separation of normal placenta from uterine
wall secondary to decidual bleeding.
 1/86 to 1/206 cases.
 Risks factors:
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Hypertensive disease,
Advanced maternal age and parity
Drug use (eg smoking, cocaine)
Trauma
Uterine anomalies eg fibroids
Sudden decompression eg ROM
Placental Abruption
Case Scenario #3
 Abruptio Placenta
 Classic Signs: vaginal bleeding, abdominal pain,
uterine contractions and tenderness
 Abruption can be concealed with no evidence of
vaginal bleeding (10-20%)
 Size of hemorrhage predictive of fetal survival >60ml
associated with >50% fetal mortality.
Case Scenario #4
Case Scenario #4
 Neonatal Resuscitation
 Assessing a Newborn- 3 questions!!
 Is the baby term?
 Is the baby breathing or crying?
 Is the baby moving with good tone or is it flaccid?
 If YES to all, then
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Clamp and cut cord 7-8 inches from insertion site
Place baby with mom
Provide warmth, dry baby’s skin
Record APGAR
Case Scenario #4
Case Scenario #4
 Neonatal Resuscitation
 If NO to any of the 3 questions, then
 Provide warmth
 Clear airways if necessary
 Stimulate baby
 Check HR: if <100- assist ventilation with bag valve
mask
 Check breathing: if labored or cyanotic- clear airway
 Re evaluate HR and breathing after intervention
Case Scenario #4
 Neonatal Resuscitation
 If HR <60 start compression
 Revaluate HR and breathing. If no change consider
intubation (hopefully you are in the ER dept)
 Establish access: umbilical vessels, IV, IO
 Medication use if condition deteriorates
 Consider possible narcotic use in mom- narcan for
reversal.
 Pneumothorax, anomalies, cardiac or respiratory
defects, blood sugar etc.
Case Scenario #5
Case Scenario #5
 Ectopic pregnancy
 Implantation of fertilized ovum outside uterine cavity
 2% of all pregnancies in USA
 Most common cause of maternal mortality in 1st
trimester
Case Scenario #5
 Ectopic Pregnancy- Risk Factors
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Prior ectopic (15-5%)
Tubal surgery (15-20%)
Tubal pathology (90%)
PID history (6-9%)
Infertility (5%)
Sterilization (33%)
Case Scenario #5
 Ectopic pregnancy
 Locations:
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Tubal 96%
Ovarian <1%
Cervical<1%
Abdominal 1.3%
Case Scenario #5
 Ectopic Pregnancy
 Signs
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Abdominal tenderness 91%
1st TM bleeding 79%
Tachycardia, low grade fever
Cervical motion tenderness
Tender pelvic or adnexal mass
Chadwick sign
Hypoactive bowel sound
Case Scenario #5
 Ectopic Pregnancy- Symptoms
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Onset about 6-7wks after LMP
Pelvic pain
Vaginal bleeding
N/V/D and dizziness
 Differential Diagnosis
 Appendicitis
 Threatened abortion
 Ruptured ovarian cyst
Case Scenario #5
 Ectopic pregnancy- Differential Diagnosis
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PID
Endometritis
Kidney stones
Normal pregnancy
UTI
 Diagnosis
 Beta HCG levels
 Ultrasound
Case Scenario #5
 Ectopic Pregnancy
 Treatment
 Expectant management
 Medical- Methotrexate( anti metabolite)
 Surgical
Case Scenario #6
Case Scenario #6
 Preeclampsia- eclampsia
 Form of hypertensive pregnancy specific disorder that
occurs after 20wks
 Characterized by vasospasm, coagulation system
activation, hyperreflexia
 Multitude of Symptoms
 Categorized: mild vs. severe preeclampsia
Case Scenario #6
 Preeclampsia-eclampsia
 Mild pre eclampsia
 BP >140/90
 +1 urine dip protein or >300mg on 24hrs
 Severe Preeclampsia
 BP >160/110
 Proteinuria >5g or 3-4+ urine dip
 Cerebral and visual disturbance
 Epigastric pain
 Pulmonary Edema
Case Scenario #6
 Preeclampsia-eclampsia
 Eclampsia
 Elevated liver enzymes
 HELLP
 Cause unknown; possible abnormal placentation or
endothelial activation
 Prevention – no proven therapy
 Low ASA
 Calcium
 Antioxidant eg Vit A
Case Scenario #6
 Preeclampsia-eclampsia
 Delivery is ONLY known treatment
 Vaginal delivery unless otherwise indicated
 Delivery based on gestational age and severity of
disease.
 Treatment
 Eclamptic Seizure prophylaxis/treatmentMagnesium sulfate IV
 Antihypertensive therapy SBP >160-180 DBP >110
Case Scenario #6
 Preeclampsia-eclampsia
 Treatment
 Monitor coagulation factors and LFTs
 Aggressive fluid management, risk of pulmonary
edema
 Monitor urine output
 Postpartum
 Continue Mg SO4 for 24hrs
 BP control, 40% recurrence rate.