First, boil water…Obstetrics for Paramedics

Rebecca Dunsmoor-Su, MD

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?

Anatomy

Anatomy

Terminology

• 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

• 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?

Physical exam

• Pulmonary• Abdominal• Uterus• Fetus• Perineum• DO NOT do an

internal vaginal exam!

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

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 presentationBreech

Footling breech

Limb presentation

Risks:

Head entrapment

Cord prolapse

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

Questions?