obstetrical emergencies - london health sciences · pdf file... period of time for...
TRANSCRIPT
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Learning Objectives
Use terminology relating to pregnancyDiscuss fetal developmentRelate complications of pregnancy and childbirth to patient presentationsApply the appropriate techniques for delivery
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TerminologyAnte partum - before deliveryPostpartum - after deliveryPrenatal - occurring before the birthGravida - number of pregnanciesPara - number of pregnancies carried to full termAbortion - pregnancy that ends before full termGestation - period of time for intrauterine fetal developmentPremature Infants - < 35 weeks (BLS) gestation, OR < 5 pounds birth weight
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Determining Stage of Pregnancy
History
• When was your last normal menstrual period (LNMP)?
• Abdominal pain? (location/quality)• Vaginal bleeding/discharge?
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Determining Stage of Pregnancy
HistoryIs there a possibility you might be pregnant?• Missed period• Increased urinary frequency• Breast enlargement • Vaginal discharge• Weight gain
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Determining Stage of Pregnancy
HistoryIf pregnant
•Subtract 3 from the month of the LNMP•Add 7 to the day of the LNMP
LNMP 2006/08/29Due date 2007/05/05
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Fetal Growth Process
First Trimester (months 1-3)• Critical Development stage for fetus• Heart is beating• Every structure found at birth is present
Second Trimester (months 4-6)• Fetal heart tones can be detected• Fetal movement may be felt by mother• Fetal growth phase
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Fetal Growth Process
Third Trimester (months 7-8)• May be capable to survive if born prematurely (fetus > 23 weeks)
• Rapid growth phase for fetus
40 weeks• Considered to have reached full term• Expected date of confinement (EDC)
Note: “youngest” to survive is 21 weeks 5 days
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Anatomy/PhysiologyUmbilical Cord
• Connects placenta to fetus
• Two arteries• One vein
Amniotic Sac• Membrane surrounding fetus
• 500 - 1000 cc (after 20 weeks)
PlacentaTransfer of gasesTransport of nutrients Excretion of wastesHormone productionProtection
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Morbidity & Mortality Rates
Accidental Injury complicates 6-7% of all pregnancies.
Most common cause of death of fetus is the death of the mother
Fetal Death with maternal survival occurs with placental separation or ruptured uterus
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Trauma in Pregnancy
Unique challenge for the provider
Two Patients each with unique needs
Mom will save herself at the expense of the fetus
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Assessment
Mother• Initial• Rapid Trauma Assessment/ Focused Assessment
Fetus• Abdominal tenderness, guarding, rigidity, rebound tenderness
• Uterus• Fetal body movements?• Contractions
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ShockBody protects the mother•uterine vasoconstriction (20-30%)•decreased blood flow to fetus
Loss of 30 - 35% blood volume before developing hypotensionSlower onset of sign/symptoms
The infant will already have been stressed by the time the mom show signs/symptoms
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ManagementC-Spine (if immobilized, tilt board)AirwayAssist ventilations if requiredHigh flow O2
(Oxygen requirements 10 - 20 % greater)Control external bleedingTransport on left side (tilt 15 to 30 degrees should be enough)Establish IV access if trained and required
Note: No servicing pregnant trauma (MVC) patients is a good way to get famous.
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Pre-eclampsia
• Acute hypertension after 24th week of gestation• 5-7% of pregnancies• Most often in first pregnancies• Other risk factors include young mothers, no
prenatal care, multiple gestation, lower socioeconomic status
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Pre-eclampsiaSign and Symptoms
Hypertension•Systolic > 140 mm Hg•Diastolic > 90mm Hg / 115 Severe Pre-EOr either reading > 30 mmHg above patient’s normal BP•Edema (particularly of hands, face) present early in day
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Pre-eclampsiaSigns and Symptoms•Rapid weight gain
>3lbs/wk in 2nd trimester>1lb/wk in 3rd trimester
•Decreased urine output•Headache, blurred vision•Nausea, vomiting•Epigastric pain•Pulmonary edema
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Pre-eclampsiaComplications
• Eclampsia• Premature separation of placenta• Cerebral hemorrhage• Retinal damage• Pulmonary edema• Pulmonary embolus• Lower birth weight infants, chronic fetal hypoxia
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Pre-eclampsia
Management100% O2Left lateral recumbent positionAvoid excessive stimulationReduce light in patient compartmentEstablish IV access if trained
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EclampsiaGravest form of pregnancy-induced hypertension Occurs in less than 1% of pregnancies
Signs and SymptomsSigns, symptoms of pre-eclampsia plus: Tonic/Clonic seizures Coma
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Eclampsia
Complications• Same as pre-eclampsia• Maternal mortality rate: 10%• Fetal mortality rate: 25%
Management• 100% O2; assist ventilations, as needed• Left lateral recumbent position• Reduce light• Manage like any major motor seizure• Emergency transport• Establish IV access if trained
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Ectopic PregnancyPathophysiology
Outside uterine cavity95% Fallopian tubes1 in every 200 pregnanciesMost are symptomaticPredisposing factors•Tubal infections•Previous tubal surgery•IUD use•Previous ectopic pregnancy
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Ectopic PregnancySigns and Symptoms
Missed menses or a decreased menstrual flow that is brownish in color
Vaginal bleed (spotting)Localized sharp pain to the affected side Abdominal pain, may radiate to shoulder from the affected sideRigid abdomen
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Ectopic PregnancyLower abdominal pain or unexplained hypovolemic
shock in a woman of child-bearing age equals Ectopic Pregnancy until proven otherwise
Management100% O2Supportive care for hypovolemic shockEstablish IV access if trainedTransport immediately
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Spontaneous AbortionAlso referred to as a “Miscarriage”Pregnancy terminates before 20th weekUsually occurs in first trimester
Signs and SymptomsVaginal bleedingCramping lower abdominal pain or pain in backPassage of fetal tissue
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Spontaneous AbortionComplications
Incomplete abortionHypovolemiaInfection, leading to sepsis
ManagementHigh concentration O2Shock positionEstablish IV access if trained and requiredTransport tissue to hospitalProvide emotional support
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Placenta PreviaImplantation of placenta over cervical opening
Signs and Symptoms•Painless, bright-red vaginal bleeding•Soft, non-tender uterus•Signs and symptoms of hypovolemia
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Placenta Previa
Management
100% O2Left lateral recumbent positionSupportive care for hypovolemic shockEstablish IV access if trained and required
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Abruptio Placentae
Premature separation of placenta from uterusHigh risk groups:•Older pregnant patients•Hypertensives•Multigravidas
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Abruptio PlacentaeSigns and Symptoms
Mild to moderate vaginal bleedingContinuous, knife-like abdominal painRigid, tender uterusSigns, symptoms of hypovolemia
Third Trimester Abdominal Pain equals Abruptio Placentae until proven otherwise
Hypovolemic shock out of proportion to visible bleeding equals Abruptio Placentae until proven otherwise
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Abruptio PlacentaeManagement
100% O2Left lateral recumbent positionSupportive care for hypovolemic shockEstablish IV access if trainedRapid transport
Note: Painless vaginal bleeding is usually placenta previa and painful vaginal bleeding is usually abruption
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Uterine RuptureCauses
• Blunt trauma to pregnant uterus• Prolonged labor against an obstruction• Labor against weakened uterine wall•Old Cesarian section scar•Grand multiparous patients
Signs and Symptoms• “Tearing” abdominal pain• Severe hypovolemic shock• Firm, rigid abdomen• Possible palpation of fetal parts through abdominal wall• Vaginal bleeding may or may not be present
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Uterine Rupture
Management
100% O2Anticipate shockEstablish IV access if trainedRequires immediate C-Section at Hospital
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ChildbirthComplications that can occur:
Breech/limb presentationMultiple BirthsUmbilical cord problemsDisproportion (Head to body size)Excessive bleedingAmniotic fluid embolism (most common cause Maternal death)Neonate requiring resuscitationPre-term labor
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Labor
1St stageOnset of contractions to dilation of cervix
2nd stageComplete dilation of cervix to delivery of baby
3rd StageDelivery of baby to delivery of placenta
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Signs of Imminent Delivery
CrowningRupture of Amniotic Sac, showNeed to bear downSensation of needing to move bowelsContractions•2 minutes (primips) to 5 minutes (multips) apart•Regular•Lasting 60-90 seconds
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DeliveryDeliver the babies head (normal delivery)Gently guide baby’s head down to deliver upper
shoulder Gently guide baby’s head up to deliver lower
shoulderGently assist with delivery of rest of babyDo NOT pull
Note time of delivery of baby
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DeliveryControl slippery baby during delivery•Support head, shoulders, feet•Keep head lower then feet to facilitate drainage of secretions from mouth
Provide warmth, keep the baby warmPosition, wipe mouth and nose unless suction is
indicatedKeep infant at mothers levelDry baby, stimulate, provide 02Assess infant, manage as required
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APGAR Score
• Developed by Virginia Apgar• Quick evaluation of infant’s pulmonary,
cardiovascular, neurological function• Useful in identifying infant’s needing
resuscitation
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Maternal Care: Postpartum
Bleeding• Place sterile pad over vaginal opening• If bleeding is excessive:
• Rapidly transport to hospital• Uterine massage• Encourage breastfeeding
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Breech Presentation
Management (Feet presentation)•High concentration O2•Rapid transport if birth not imminent•Prepare for neonatal resuscitation•Establish IV access if trained•Assist delivery•Frank (butt), Load and GO
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Limb Presentation
Management
•DO NOT attempt delivery•Position on Left side with knees / hips flexed•Administer Oxygen•Establish IV access if trained•Discourage pushing (have patient “pant & blow)•Prepare for deliver / resuscitation
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Prolapsed CordUmbilical cord enters vagina before infant’s headPressure of head on cord occludes blood flow, O2 delivery to fetus
Management•With a gloved hand palpate the cord for a pulse (If pulse is weak or absent – relieve cord compression by inserting two gloved fingers into the vagina and gently move the part away from the cord)•Administer oxygen•Cover the cord with gauze moistened with saline•IV access if trained•Transport patient in prone (knees to chest) position
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Amniotic Sac Intact
ManagementUse clamp to tear sac, release fluidMove sac away from baby’s nose, mouthPrepare to suction at the perineum and post delivery
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Multiple BirthsConsider as possibility if: •Mother’s abdomen appears abnormally large prior to delivery•Mother’s abdomen remains large after delivery of first baby•Contractions continue after delivery of first baby
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Multiple BirthsDelivery of Multips:
• Clamp cord of first baby before delivery of second
• Usually second baby will deliver shortly after first
• Care for babies, mother, and placenta(s) as you would in a single birth
Multiple babies are usually smallIt is important to keep them warm!
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Review (of objectives)
Self evaluation – After attending this …..Can you effectively communicate usingterminology related to pregnancy?Can you discuss maternal changes and fetal
development that occur during pregnancy?Can you relate the complications of pregnancyand childbirth covered to patient presentations?
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References
Bledsoe, Porter, Cherry and Clayden.(2000).Essentials of Paramedic CareCanada: Pearson Education Canada
Emergency Health Services Branch. Ontario Ministry of Health and Long Term Care.(2007). Basic Life Support Patient Care Standards, version 2.0 . Toronto, CA.
Hill,C.C, & Pickinpaugh, J. (2008). Trauma and Surgical Emergencies in the Obstetric patient. Surg Clin North Am, 88(2):421-40,viii.
Kornelsen, J.A. & Grzybowski, S.W. (2008). Obstetric Services in small rural communities: What are the risks to care providers? Rural Remote Health. 8(2):943