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Module16

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

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Module16 1.2.1.3 Amnioticsacandfluid


Obstetrics

Membranesurroundingthefoetus Fluidoriginatesfromfoetalsources(urine,secretions) o Fluidaccumulatesrapidly o 15thweekofpregnancy+175225mloffluid o Atbirth(40weeksgestation)+1L Ruptureofthemembraneproduceswaterydischarge

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

Foetus st Endof1 trimester 12weeks

Foetus Endof4months 16weeks

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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)

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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

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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 Medical 2.1.2.1 Preeclampsia


Diseaseoriginunknown Primarilyaffectspreviouslyhealthy&normotensivePrimigravida(Pregnantforthefirsttime) o Normotensivechangesintohypertensive/hypertension Occursoften20thweekofgestationoftennearterm(3842weekgestation)

2.1.2.2 Eclampsia
CharacterizedbysamesignsandsymptomsasPreeclampsiaandseizures/coma CriteriafordiagnosisofPreeclampsiabasedonpresenceof o Classictriad Hypertension BPhigherthan140/90mmHG Acuteriseof20mmHGsystolicpressure Orriseof10mmHGindiastolic o Overrepregnancylevels Proteinuria Excessiveweightgainwithoedema Sacral/pedaloedema

2.1.3 VaginalBleeding 2.1.3.1 Abortion


Terminationofpregnancy Canbefromanycausebefore20thweekgestation(afterwhichitiscalledpretermbirth) 5typesofabortions o Inducedabortion(clinics) o Spontaneousabortion(miscarriage) o Complete(everythingisexpelled) o Incomplete(piecesofthefoetusisexpelled) o Missedabortion(foetusisdeadbutnotexpelledbythebody) HistorytakingMUSTdetermine o Onsetofpain o Bleeding Amountofbloodloss o Ifpt.passedanytissuewithblood

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Module16 2.1.3.1.1

Obstetrics

AssessmentandManagementAbortion

Callforbackup Highconcentrationofoxygen VitalSigns(AssessandReassess) SAMPLE History

2.1.3.2 Ectopicpregnancy
Occurswhenfertilizedovumimplantsanywhereotherthanendometriumofuterinecavity classictriadofsymptoms o Abdominalpain o Vaginalbleeding o Amenorrhea

2.1.3.2.1

AssessmentandManagementEctopicpregnancy

Callforbackup Highconcentrationofoxygen VitalSigns(AssessandReassess) SAMPLE History

2.1.4 ThirdTrimesterBleeding 2.1.4.1 Abruptionplacenta


Partial/completedetachmentofnormalimplantedplacenta o Morethan20weeksgestation

2.1.4.2 PlacentaPrevia

Placentalimplantationinloweruterinesegmentencroachingon/coveringcervicalos(os:opening)

2.1.4.3 Uterinerupture

Spontaneous/traumaticruptureofuterinewall

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Module16 2.1.4.3.1

Obstetrics

AssessmentandManagementThirdtrimesterbleeding

Managementofthirdtrimesterbleedingaimedatpreventionofshock NOattemptshouldbemadetoexaminept.vaginally o Doingsomayincreasehaemorrhaging o Andorprecipitatelabour Emergencycare Callforbackup Highconcentrationofoxygen VitalSigns(AssessandReassess) SAMPLE History TransportASAP

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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

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Module16 3.2 SignsandSymptomsoflabour/delivery

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

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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

/10 Appearance 0 Infantblue Extremitiesblue, 1 bodypink 2 Entirebodypink

Activity Limp Weakattemptstoprevent straightening

Respirations Absentrespirations Slowrespiration Normal Respirations

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)***

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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

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Module16 3.13 Foetalmembranedisorder


Obstetrics

Prematureruptureofmembrane Ruptureofamnioticsacbeforeonsetoflabour o Regardlessofgestationperiod Signsandsymptomsincludehistoryofatrickle/suddengushoffluidfromvagina Transporttophysicianevaluation

3.14 Amnioticfluidembolism
Mayoccurwhenamnioticfluidgainsaccesstomaternalcirculationduringlabour/delivery/immediatelyafter delivery

3.15 Meconiumstaining
Presenceoffoetalstoolinamnioticfluid o Greenishblackcolour o Signsthatthefoetus/infantisinseverestress

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