Post on 17-Dec-2015
transcript
Outline
• The basics (anatomy, terminology)• Normal pregnancy• Abnormal pregnancy
– First trimester– Later
• Trauma• Normal labor & delivery• Abnormal labor & delivery• What do you do with the baby?
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
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
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
• Gs and Ps• LMP / EDC• Bleeding?• Leaking fluid?• Contracting?• Baby moving?• Medical
Comorbidities?• Any prenatal care?
• 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?
Abnormal pregnancyFirst 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 pregnancyFirst Trimester
• 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
uterus
ectopic
Abnormal pregnancyafter 20 weeks
Bleeding:
• Placenta previa
• Placental abruption
• Preterm labor
• PPROM
Medical:
• Pre-eclampsia
• Eclampsia
• Diabetes
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
Sometimes hard to diagnose
Often caused by infection
Associated with increased risk of abruption, cord prolapse, cerebral palsy (when accompanied by infection)
Preterm Premature Rupture of Membranes
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 3-4cm)
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
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
Breech deliveryAllow 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
• 0.5-1% risk in women with one prior C-section
• 5-50% risk of fetal death
• Risk of maternal hemorrhage
Signs:
• Vaginal bleeding
• Loss of fetal station
• Abdominal pain
• 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
Circulation & Color
Tone & Reflexes
Dry the baby and keep her warm: skin to skin is best
APGAR Score
Appearance:
0 = blue or white
1 = pink body, blue extrem.
2 = pink
Pulse
0 = absent
1 = <100
2 = >100
Grimace:
0 = No response
1 = grimace
2 = Cries
Activity
0 = limp
1 = Some flexion
2 = Active movement
Respiration
0 = Absent
1 = Slow or irregular
2 = Strong cry
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
Evaluate respirations, heart rate and color
Positive-pressure ventilation
Chest compressions
Epi
Apnea
HR <100
HR <60 HR <60
Poor colorBlow-by O2Stimulation
Consider intubation