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Obstetrics

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Information about Obstetrics
Education

Published on October 15, 2008

Author: aSGuest1088

Source: authorstream.com

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Obstetrics : Obstetrics EMS Professions Temple College Pregnancies : Pregnancies Most are uncomplicated Complications can arise from: Eclampsia/Pre-eclampsia Diabetes Hypotension/Hypertension Cardiac disorders Abortion Trauma Placenta abnormalities Childbirth : Childbirth Involves Labor and Delivery Natural process, often only requiring basic assistance Childbirth : Childbirth You have at least two patients! Childbirth : Childbirth Complications can occur Breech/limb presentation Multiple Births Umbilical cord problems Disproportion Excessive bleeding Pulmonary embolism Neonate requiring resuscitation Preterm labor Female Reproductive System : Female Reproductive System Female Reproductive System : Female Reproductive System Anatomy/Physiology : Anatomy/Physiology Ovulation Fertilization Implantation Anatomy/Physiology : Anatomy/Physiology Placenta Transfer of gases Transport of nutrients Excretion of wastes Hormone production Protection Anatomy/Physiology : Anatomy/Physiology Umbilical cord Connects placenta to fetus Two arteries One vein Amniotic Sac Membrane surrounding fetus Fluid originates from feral sources 500 - 1000 cc (after 20 weeks) Rupture produces watery discharge Terminology : Terminology Antepartum - before delivery Postpartum - after delivery Prenatal - occurring before the birth Natal - connected with birth Gravida - number of pregnancies Para - number of pregnancies carried to full term Abortion - number of pregnancies that ended before full term Primigravida - woman who is pregnant for the first time Primipara - woman who has given birth to her first child Multiparous - woman who has given birth multiple times Gestation - period of time for intrauterine fetal development Fetal Growth Process : Fetal Growth Process End of third month Sex may be distinguished Heart is beating Every structure found at birth is present End of fifth month Fetal heart tones can be detected Fetal movement may be felt by mother End of sixth month May be capable to survive if born prematurely Middle of tenth month Considered to have reached full term Expected date of confinement (EDC) Ectopic Pregnancy : Ectopic Pregnancy Pathophysiology Outside uterine cavity 95% Fallopian tubes 1 in every 200 pregnancies Most are symptomatic Predisposing factors Tubal infections Previous tubal surgery IUD use previous ectopic pregnancy Ectopic Pregnancy : Ectopic Pregnancy History Missed period Other signs of early pregnancy Vaginal bleeding 6 -8 weeks after last period Upon rupture, bleeding may be excessive Ectopic Pregnancy : Ectopic Pregnancy History Lower abdominal pain May be: Sharp or dull Constant or intermittent Diffuse or localized May be referred to shoulder Ectopic Pregnancy : Ectopic Pregnancy Physical Exam S/S of hypovolemic shock Positive tilt test Tender lower abdomen Palpable mass may be present Ectopic Pregnancy : Ectopic Pregnancy Abdominal pain or unexplained hypovolemia + woman of child-bearing age = Ectopic pregnancy Until proven otherwise! Ectopic Pregnancy : Ectopic Pregnancy Management High concentration oxygen IV or IV’s with LR MAST Immediate transport Abortion : Abortion Termination of pregnancy before fetal viability (20th week) Abortion : Abortion Induced Therapeutic Criminal Elective Abortion : Abortion Spontaneous 20 -25% of pregnancies terminate spontaneously Usually due to embryo abnormalities May also result from infection, unfavorable intrauterine environment, cervical incompetence Abortion : Abortion Spontaneous Threatened Inevitable Complete Incomplete Abortion : Abortion Threatened Vaginal bleeding, mild or absent contractions, closed cervix 20% of women bleed in early pregnancy 50% go on to abort Any bleeding in early pregnancy is dangerous and abnormal Abortion : Abortion Inevitable Vaginal bleeding Moderately severe contractions Possible amniotic sac rupture Cervix effacement and dilation Changes are irreversible Abortion : Abortion Completed Products of conception expelled fetus placenta decidual lining Signs, symptoms Profuse vaginal bleeding Passage of tissue, clots Continuing mild contractions Possible hypotension Abortion : Abortion Incomplete Products of conception retained Signs, symptoms Profuse bleeding Passage of tissue/clots Severe contractions Hypotension, shock Sepsis Abortion : Abortion Missed Fetus dies in utero before 20th week Retained at least 2 months afterwards Abortion : Abortion Missed Signs/Symptoms Continued amenorrhea History of bleeding without cramping Decrease in uterine size Resorption of fluid Calcification of products of conception Abortion : Abortion History Confirmed or suspected pregnancy Abdominal pain, cramping Bleeding, passage of tissue Abortion : Abortion Physical Exam Orthostatic vital signs (tilt test) Examine for amount of vaginal bleeding, presence of tissue Abortion : Abortion Management High concentration oxygen IV or IV’s with LR MAST if indicated Do NOT pack vagina Save any tissue passed Transport Medical Complications : Medical Complications Diabetes Stable may become unstable Gestational Can not use oral medications Neuromuscular May be aggravated by pregnancy Medical Complications : Medical Complications Hypertension More susceptible to complications CVA Cardiac Failure Renal Failure May be complicated by preeclampsia or eclampsia Cardiac Disorders Additional stress placed on heart CO increases 30% by week 34 Pregnancy-Induced Hypertension : Pregnancy-Induced Hypertension Two Phases: Pre-eclampsia Eclampsia Pre-Eclampsia : Pre-Eclampsia In about 7% of pregnancies Between 20th week gestation, first week postpartum Hypertension, albuminuria, edema Pre-Eclampsia : Pre-Eclampsia Risk Factors First pregnancies Multiple gestations excessive amniotic fluid Diabetes mellitus Renal disease Pre-existing hypertension Family history of pre-eclampsia Poor nutrition Pre-Eclampsia : Pre-Eclampsia Signs/Symptoms Elevated BP >140/90 or >30mmHg above patient normal Edema of face/hands Especially in morning Pre-Eclampsia : Pre-Eclampsia Signs/Symptoms Rapid weight gain >3lb/wk - 2nd trimester >1lb/wk - 3rd trimester Decreased urine output Pre-Eclampsia : Pre-Eclampsia Signs/Symptoms Severe headache Blurred vision Irritability Nausea, vomiting Epigastric pain Pulmonary edema Eclampsia : Eclampsia Pre-eclampsia + Seizures, Coma PIH : PIH Management High concentration oxygen IV tko Left lateral recumbent position Quiet environment Reduce excessive light PIH : PIH Psychological support Avoid lights/sirens in pre-eclampsia Magnesium sulfate 4gm bolus; 1gm/hr infusion Monitor pulse, BP, respiration, patellar reflex Calcium will reverse toxicity PIH : PIH Assess every pregnant patient for: Increased BP Edema Take all reported seizures in pregnant females seriously Third Trimester Bleeding : Third Trimester Bleeding 50% due to normal changes in cervix 50% due to placental catastrophe Dangerous if amount greater than normal period Abruptio Placentae : Abruptio Placentae Premature placental separation from uterus 0.4 - 3.5% of pregnancies Risk Factors Older patients Hypertensives Multigravidas Trauma Abruptio Placentae : Abruptio Placentae Mild to moderate vaginal bleeding Continuous, knife-like abdominal pain Third trimester pain = Abruption until proven otherwise Rigid tender uterus S/S of hypovolemia Out of proportion to visible bleeding Alteration of contraction pattern Placenta Previa : Placenta Previa Placental implantation over cervical opening 0.5% of pregnancies Predisposing factors increasing age multiparity previous cesarean sections Can lead to placental insufficiency fetal hypoxia Placenta Previa : Placenta Previa Painless, bright-red vaginal bleeding Soft, non-tender uterus No contractions S/S of hypovolemia Third Trimester Bleeding : Third Trimester Bleeding Management 100% Oxygen IV of LR x 2 Left lateral recumbent position MAST, legs only Assess fetal heart tones? Third Trimester Bleeding : Third Trimester Bleeding Never perform vaginal exam on third trimester patient with vaginal bleeding Hyperemesis Gravidarum : Hyperemesis Gravidarum Severe nausea, vomiting Leads to starvation, dehydration, acidosis Continued vomiting in pregnancy with loss of weight Hyperemesis Gravidarum : Hyperemesis Gravidarum Management Replace lost fluids, electrolytes Glucose Supine Hypotensive Syndrome : Supine Hypotensive Syndrome Uterus compresses inferior vena cava Venous return to heart decreases Decreased venous return leads to decreased cardiac output BP decreases Consider volume depletion Supine Hypotensive Syndrome : Supine Hypotensive Syndrome Management Place patient on left side to restore venous return Transport all non-laboring patients in late pregnancy on left side Ruptured Membranes : Ruptured Membranes Vaginal leakage of clear, colorless fluid 84% labor spontaneously in 24 hours, BUT 50% become infected in 12 hours Increased time = Increased infection risk Patient MUST come to hospital Fever/Dysuria : Fever/Dysuria Major medical emergency Suggests urinary tract or amniotic fluid infection Sepsis or early labor may result Patient MUST come to hospital Uterine Rupture : Uterine Rupture Common causes: Prolonged labor against obstruction Large fetus Old C-section Multiple pregnancies Uterine Rupture : Uterine Rupture Signs/Symptoms Sudden, intense, tearing abdominal pain S/S of hypovolemic shock Loss of continuity of uterine mass Possible vaginal bleeding Uterine Rupture : Uterine Rupture 50 - 75% fetal mortality Management 100% Oxygen IV of LR x 2 Left lateral recumbent position MAST, legs only Rapid transport Uterine Rupture : Uterine Rupture History of previous C-section Transport immediately unless baby is crowning Determine reason for C-section Trauma in Pregnancy : Trauma in Pregnancy Minor Trauma Common in the Obstetric Patient Syncopal episodes Diminished coordination Loosening of the joints Trauma in Pregnancy : Trauma in Pregnancy Major Trauma Susceptible to a life threatening episode increased vascularity may deteriorate suddenly Leading cause of maternal death in pregnancy MVC’s = 50% of perinatal mortality Trauma in Pregnancy : Trauma in Pregnancy Trauma can lead to Premature separation of the placenta Premature labor Abortion Rupture of the uterus Fetal death Death of mother Separation of the placenta Maternal shock Uterine rupture Fetal head injury Trauma in Pregnancy : Trauma in Pregnancy Injured woman of child-bearing age, consider pregnancy Priorities EXACTLY same as in any other patient ABC’s first Trauma in Pregnancy : Trauma in Pregnancy Assessment Vital signs mimic hypovolemia Pulse increases 10-15/minute BP decreases Trauma in Pregnancy : Trauma in Pregnancy Assessment Blood volume increases up to 45% More blood loss can occur before S/S of hypovolemia appear In hypovolemia, blood is shunted from placenta causing fetal distress Trauma in Pregnancy : Trauma in Pregnancy Assessment Increased fluid volume needed to treat hypovolemia Penetrating abdominal trauma in second, third trimester frequently involves uterus Greatest danger from uterine injury is hypovolemia Trauma in Pregnancy : Trauma in Pregnancy Assessment Second, third trimester blunt abdominal trauma may cause: Uterine rupture Placental abruption Premature labor Hemorrhage from uterine vessels Trauma in Pregnancy : Trauma in Pregnancy Assessment “Loose” joints mimic orthopedic injury Particularly pelvic fracture Trauma in Pregnancy : Trauma in Pregnancy Management Treat shock early, aggressively Fetus may be distressed when mother is not S/S of shock appear later More volume needed to correct hypovolemia Trauma in Pregnancy : Trauma in Pregnancy Management Oxygenate aggressively Consider assisting ventilation early Oxygen demand increases 10-20% in last trimester High diaphragm causes decreased compliance, tidal volume Trauma in Pregnancy : Trauma in Pregnancy Management MAST can be used in late-term pregnancy Inflate legs only Using abdominal compartment reduces blood flow to fetus Trauma in Pregnancy : Trauma in Pregnancy After first trimester never transport patient flat on back Transport on left side Prop up right side of spine board with blanket, pillows Trauma in Pregnancy : Trauma in Pregnancy Most common cause of fetal death from trauma is maternal death Keeping mom alive keeps baby alive What’s good for mom is good for baby Braxton-Hicks Contractions : Braxton-Hicks Contractions Usually occurs in the third trimester Benign phenomenon that simulates labor Contractions are generally painless Walking may help Preterm labor : Preterm labor Labor that begins prior to 38 weeks gestation Labor results in progressive dilation and effacement of cervix Causes Multiple gestations Intrauterine infections Premature rupture of the membranes Uterine or cervical anatomical abnormalities Preterm labor : Preterm labor Management Consideration of tocolysis Rest Fluids Sedation Transport for evaluation Obstetric Patient Assessment : Obstetric Patient Assessment Obstetric PA : Obstetric PA Recognition of pregnancy Breast tenderness Urinary frequency Amenorrhea Nausea/Vomiting Obstetric PA : Obstetric PA Obstetric History Gravidity and Parity Gravidity = Number of pregnancies Parity = Number of live births Obstetric PA : Obstetric PA Obstetric History Last normal menstrual period Estimated delivery date (-3/+7) Previous Ob-Gyn complications Prenatal care (by whom) Previous Cesarean sections Obstetric PA : Obstetric PA Obstetric Physical Exam Evaluation of Uterine Size 12 to 16 weeks: above symphysis pubis 20 weeks: at umbilicus For each week beyond 20 weeks: 1 cm above umbilicus At term: near xiphoid process Obstetric PA : Obstetric PA Obstetric Physical Exam Presence of fetal movements ~20th week Presence of fetal heat tones ~20th week Normal: 120 to 160/minute Obstetric PA : Obstetric PA Presence of Pain Abdominal pain in last trimester suggests abruption until proven otherwise Appendicitis may present with RUQ pain Obstetric PA : Obstetric PA Presence of vaginal bleeding Always dangerous in first trimester Dangerous in late pregnancy if greater than normal period Obstetric PA : Obstetric PA General health Diabetes may become unstable Hypoglycemic episodes in early pregnancy Hyperglycemia as pregnancy progresses Hypertension complicated by PIH Cardiovascular disease may worsen Obstetric PA : Obstetric PA Do tilt test if blood loss is suspected Do NOT tilt patient with obvious shock Obstetric PA : Obstetric PA Do NOT perform vaginal exams Obstetric PA : Obstetric PA Warning signs Vaginal bleeding Swelling of face, hands Dimmed, blurred vision Abdominal pain Obstetric PA : Obstetric PA Warning signs Persistent vomiting Chills, fever Dysuria Fluid escape from vagina

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