Professional Documents
Culture Documents
Obstetrics
1
1.1
Obstetrics
Terminology
Totalofallofthewoman'scurrentandpastpregnancies Pregnantforthefirsttime Twoormorepregnancies Totalofthewoman'spastviablepregnanciesremainedtodelivery Neverdelivered Givenbirthonlyonce Twoormoredeliveries Sevendeliveriesormore Connectedwithbirth Maternalperiodbeforedelivery Maternalperiodafterdelivery Occurringatornearthetimeofbirth Existingoroccurringbeforebirth periodofintrauterinefoetaldevelopment Pregnancythathasreached40weeksgestation
GRAVIDA PRIMIGRAVIDA MULTIGRAVIDA PARA NULLIPARA PRIMIPARA MULTIPARA GRANDMULTIPARA NATAL ANTEPARTUM POSTPARTUM PERINATAL PRENATAL GESTATION TERM
1.2
Normaloccurrencesduringpregnancy
Ovulation Fertilization o Occursinthirdoffallopiantub Implantation o Occursinuterus
1.2.1
SpecializedStructures
Placenta Umbilicalcord Amnioticsacandfluid
1.2.1.1 Placenta
Responsiblefor: o Transferofgases o Transportofothernutrients o Excretionofwastes o Hormonesproduction o Protection
1.2.1.2 Umbilicalcord
Connectedtothefoetusandplacenta Containstwoarteriesandonevein
1/12
Obstetrics
1.2.2
Foetalgrowthanddevelopment
Duringfirst8weeksofpregnancy o Developingovumknowisembryo After8weeksuntilbirth o Calledfoetus Gestationusuallyaverages3842weeksfromfertilizationtodeliver Progressofgestationusuallyconsideredintermsof90dayperiods/trimesters Surfactantproducedby20thweekofgestation o Surfactantreducessurfacetensionofliquidfilmcoveringinnerliningofpulmonaryalveoli o Reducessurfacetensionandinturnpreventsalveolifromcollapsing
Embryo&Foetus 5weeks@35days
Foetus 7weeks@49days
2/12
Module16 1.2.3
Obstetrics
Maternalchangesduringpregnancy
Cessationofmenstruation Enlargementofuterus Manyotherphysiologicalchangeseffecting: o Genitaltract Hypertrophy&softeningofcervix o Breasts Increaseinsize o Gastrointestinalsystem Increaseinappetite/nausea/vomiting o Cardiovascularsystem Vascularresistancedecrease =Restingheartrate =increaseincardiacoutput o Respiratorysystem Tidalvolume&minutevolumeincrease o Metabolism Basalmetabolismincrease
1.3
ObstetricsHistoryTaking
Lengthofgestation(howfaralongisthepregnancy) Gravidity&Parity(G_P_)[mom:G3P2) o G:totalpregnanciesP:totalviabledeliveries(natural/orsurgical) Previouscaesareandelivery Maternallifestyle o Alcohol,drugs,smokerornotandhowmanyaday STDsInfectiousdiseasestatus Historyofpreviousgynaecological/obstetricalcomplication o Miscarriage/abortion/endometriosis/PID Presenceof: o Pain o Vaginalbleeding(quantityandcharacter) o Abnormalvaginaldischarge PresenceofSHOW o Expulsionofmucouspluginearlylabour/rupturemembranes Currentgeneralhealthandprenatalcare o Physician/nurse/midwife/none SAMPLE o Allergies/medication o Especiallyuseofnarcoticsinlastfourhours Maternalurgetobeardown/sensationofimminentbowelmovement o Thisissuggestionofimminentdelivery o Signsofcontracts
1.4
Physicalexamination
Pt.chiefcomplaintdeterminesextentofphysicalexamination o Prehospitalobjective Rapidlyidentifyingacutesurgical/lifethreateningconditions Rapidlyidentifyingimminentdeliverandtakeappropriatemanagementsteps Evaluatept.generalappearanceandskincolour Vitalsigns(frequentlyassess&reassess) Examineabdomenfor o previousscars o abdominalgrossdeformities(e.g.hernia/markedabdominaldistension)
3/12
Module16 1.5
Obstetrics
Changesinfundalheight Weeks10term(3842weeks)
Evaluationofuterinesize
Uterinecontourusuallyirregularbetween810weeks o Earlyuterineenlargementmaynotbesymmetrical o Uterusmaybedeviatedtooneside 1216weeksuterusisabovepubicsymphysis 24weeksuterusisatthelevelofumbilicus Atterm(3842weeksgestation)uterusnearxiphoidprocess
1.6
Foetalmonitoring
Foetalheartsoundsmaybeauscultated o 1640 Auscultateusing o Stethoscope/foetalscope/Doppler Normalfoetalheartrate o 120160bpm
GeneralObstetricsManagement
Ifbirthnotimminent o Careforhealthoftenlimitedtobasictreatmentmodalities Absenceofdistress/injury o Transportpt.inpositionofcomfort(usuallyleftlateral) VitalSigns SAMPLE Highconcentrationofoxygenadministration o Foetalmonitoringmaybeindicatedforsomept.basedofpt.vitalsignsandassessment ECGmonitoring(CanonlybedonebyAEAifyouhavecalledforbackup)
2.1
Complicationofpregnancy
Trauma Medical o Preeclampsia o Eclampsia VaginalBleeding o Abortion o Ectopicpregnancy ThirdTrimesterBleeding o Abruptionplacenta o PlacentaPrevia o Uterinerupture
2.1.1
Trauma
Causes o MVA(mostoften) o Fall o Penetratingobjects(leastoften) Greatriskoffoetaldeathis: o Foetaldistress o Intrauterinedemise(causebytraumatomother/herdeath) Pregnanttraumapt.promptlyassess/interveneonbehalfofmother
4/12
Module16 2.1.1.1.1
Obstetrics
Pregnanttraumapt.AssessmentandManagement
Assesspt. Presenceof: o Pain o Vaginalbleeding(quantityandcharacter) o Abnormalvaginaldischarge SAMPLE o Allergies/medication o Especiallyuseofnarcoticsinlastfourhours Lengthofgestation Gravidity&Parity(G_P_)[mom:G3P2) Highconcentrationofoxygen Maternalurgetobeardown/sensationofimminentbowelmovement o Thisissuggestionofimminentdelivery o Signsofcontracts Specialmanagementconsideration: o CallforadoctororALS Transportationstrategies
2.1.2.2 Eclampsia
CharacterizedbysamesignsandsymptomsasPreeclampsiaandseizures/coma CriteriafordiagnosisofPreeclampsiabasedonpresenceof o Classictriad Hypertension BPhigherthan140/90mmHG Acuteriseof20mmHGsystolicpressure Orriseof10mmHGindiastolic o Overrepregnancylevels Proteinuria Excessiveweightgainwithoedema Sacral/pedaloedema
5/12
Module16 2.1.3.1.1
Obstetrics
AssessmentandManagementAbortion
2.1.3.2 Ectopicpregnancy
Occurswhenfertilizedovumimplantsanywhereotherthanendometriumofuterinecavity classictriadofsymptoms o Abdominalpain o Vaginalbleeding o Amenorrhea
2.1.3.2.1
AssessmentandManagementEctopicpregnancy
2.1.4.2 PlacentaPrevia
Placentalimplantationinloweruterinesegmentencroachingon/coveringcervicalos(os:opening)
2.1.4.3 Uterinerupture
Spontaneous/traumaticruptureofuterinewall
6/12
Module16 2.1.4.3.1
Obstetrics
AssessmentandManagementThirdtrimesterbleeding
Managementofthirdtrimesterbleedingaimedatpreventionofshock NOattemptshouldbemadetoexaminept.vaginally o Doingsomayincreasehaemorrhaging o Andorprecipitatelabour Emergencycare Callforbackup Highconcentrationofoxygen VitalSigns(AssessandReassess) SAMPLE History TransportASAP
7/12
Module16
Obstetrics
3
3.1
LabourandDelivery
StagesofLabour
Stage1 o LatentPhase Longeststageoflabour Canrangefrom1220hours(forwomanhaving1stbaby) Beginswithonsetofregularcontraction Endswhencervixhasdilatedto34cm Activephase Contractionbecomestrongerandmorepainful Hiswillcontinuetillcervixhasdilatedto810cm 10cmpt.isfullydilated Progressofbabysdecentthroughpelvisismeasuredinnumbercalledstations Stationsaremeasureuntilbabyisborn Beginswithdeliveryoftheinfant Endswhenplacentahasbeenexpelledanduterushascontracted
Stage2 o o o Stage3 o o
8/12
Obstetrics
Ifanyofthesesignsandsymptomsispresent,preparefordelivery: Regularcontractions o Lasting4060sec o 12minintervals Motherhasurgetobeardown/hassensationofbowelmovement Largeamountofbloodyshow Motherbelievedeliveryisimminent**** Delay/restraintofdeliveryshouldnotbeattempted o Expectcordpresentation Ifcomplicationanticipated/abdominaldeliveryoccurs o Medicaldirectionmayrecommendexpeditedtransport Preparefordelivery o Deliveryequipment
3.3
Assistingwithdelivery
Mostcases,paramedicsonlyassistinnaturaleventsofchildbirth PrimaryresponsibilityofEMS o Preventanuncontrolleddelivery o Protectinfantfromcoldandstressafterbirth(spaceblanket)
3.3.1
Assistingwithdeliveryconsistsof
Deliveryprocedure Evaluatinginfant Cuttingumbilicalcord Deliveryoftheplacenta Initiatefundalmassagetopromoteuterinecontracts
3.3.1.1 Normaldelivery
Atcrowning o Applygentlepalmpressuretoinfantshead o Examinetheneckforpresenceofloopedumbilicalcord o Supportinfantsheadasitrotatesforshoulderpresentation o Guideinfantsheaddownwardstodeliveranteriorshoulder o Guideinfantsheadupwardstoreleaseposteriorshoulder
9/12
Module16
Obstetrics
Delivery o Afterdelivery o Evaluationinfant(APGARscore) o Clampandcutumbilicalcord Measure: Clampat4fingerawayfromthestartoftheinfantsideumbilicalcord Clampforfingerawayfromthe1stclamp Waitforthepulsetostopbetweenthetwoclamps Thencutthecord o Initiatefundalmassagetopromoteuterinecontraction
3.3.2
DeliveryComplications
Factorsassociatedwithhighriskabdominaldelivery o Maternalfactors o Foetalfactors
3.4
APGARscore
Pulse Grimace AbsentPulse NoCrying Weakcryto <100bpm stimulus >100bpm
Activecrying Active
APGARscoreistobetakenstraightafterdeliveryofbaby And5minafterdelivery
3.5
Cephalopelvicdisproportion
Producesdifficultlabourduetopresenceofsmallpelvis/oversizedfoetus/foetalabnormalities o E.g.hydrocephalus,conjoinedtwins,foetaltumour MotherisoftenPrimigravida o Andexperiencesstrong,frequentcontractionsforprolongedperiods Prehospitalcarelimitedto o Maternaloxygen o Rapidtransporttomedicalfacility o IVaccessforfluidresuscitationifneeded(ILS/ALS)
3.6
PostpartumHaemorrhage
Morethan500mlbloodlossafterdeliveryofinfant
3.7
Abnormalpresentation
Mostinfantsarebornheadfirst o Normalpresentation Cephalicorvertexpresentation Onrareoccasions,presentationisabnormal o Breechpresentation*** o Shoulderpresentation(transversepresentation) o Shoulderdystocia o Cordpresentation(prolapsedcord)***
10/12
Module16
Obstetrics
3.8
Goalsofprehospitalmanagement
Earlyrecognitionofpotentialcomplication Maternalsupportandreassurance Rapidtransportfordefinitivecare
3.9
Prematurebirth
Aprematureinfantisbornbefore37weeksofgestation
3.10 Multiplegestations
Pregnancywithmorethanonefoetus Associatedcomplications Deliveryprocedure
3.11 Precipitousdelivery
Rapidspontaneousdelivery Withlessthan3hoursfromonsetoflabourtobirth Resultsforoveractiveuterinecontractions Littlematernalsofttissue/bonyresistance
3.12 Pulmonaryembolism
Developmentofpulmonaryduringpregnancy/labour/postpartumperiod Oneofmostcommoncausesofmaternaldeath
11/12
Obstetrics
3.14 Amnioticfluidembolism
Mayoccurwhenamnioticfluidgainsaccesstomaternalcirculationduringlabour/delivery/immediatelyafter delivery
3.15 Meconiumstaining
Presenceoffoetalstoolinamnioticfluid o Greenishblackcolour o Signsthatthefoetus/infantisinseverestress
12/12