Obstetrics and Pregnancy Study Notes (6th Edition)

Review of Female Reproductive Anatomy (1 of 2)

  • Female reproductive system structures

    • External: Labia minora, labia majora, vagina (birth canal), clitoris

    • Internal: Uterus, ovaries, uterine (fallopian) tubes, cervix

  • Reproductive cycle (for persons of childbearing age)

    • Usually a monthly event

    • Begins with menstruation and, if fertilization occurs, ends with pregnancy

Normal Events of Pregnancy (1 of 3)

  • Fertilization

    • Normally occurs in the fallopian tube when the head of the sperm penetrates a mature ovum

    • Nuclei of sperm and ovum fuse; newly fertilized ovum becomes a zygote

  • Early embryo development

    • Zygote undergoes repeated cell divisions as it passes down the fallopian tube

    • After rapid cell division, a ball of cells forms: morula (with inner and outer cell differentiation)

    • Blastocyst consists of an inner cell mass (which becomes the embryo) and extraembryonic structures

  • Trophoblast and placental development

    • Trophoblast forms the outer layer of the blastocyst

Normal Events of Pregnancy (2 of 3)

  • Implantation

    • Begins within ~7 days after fertilization

    • Completed when trophoblast cells contact maternal circulation (about day 12)

  • Trophoblast derivatives

    • Placenta

    • Amniotic sac

    • Umbilical cord

  • Blastocyst development

    • Blastocyst cells develop into the embryo itself

Normal Events of Pregnancy (3 of 3)

  • Overall pregnancy structure

    • Fetal development depends on placental exchange and amniotic environment

  • Gestation duration

    • Averages 4040 weeks from fertilization to delivery

    • Divided into trimesters

    • Calculated delivery date referred to as the estimated date of confinement (EDC/EDD)

Specialized Structures of Pregnancy (1 of 4)

  • Placenta

    • Disklike organ composed of interlocking fetal and maternal tissues

    • Organ of exchange between mother and fetus

    • Responsible for: transfer of gases, transport of nutrients, excretion of wastes, hormone production, formation of a barrier

Specialized Structures of Pregnancy (3 of 4)

  • Fetal circulation (differences from maternal circulation)

    • Physically separated from but dependent on maternal circulation

    • Umbilical vein — carries oxygenated blood from placenta to fetus

    • Umbilical arteries — carry deoxygenated blood from fetus to placenta

    • Ductus venosus — shunt allowing blood returning from placenta to bypass the immature liver of the embryo

    • Blood moves from right atrium to left atrium through foramen ovale

    • Ductus arteriosus connects pulmonary artery to aorta, directing blood away from lungs

  • At birth

    • Arteriovenous shunts close in response to inflation of lungs

Specialized Structures of Pregnancy (4 of 4)

  • Amniotic sac and amniotic fluid

    • Amniotic sac completely surrounds the embryo

    • Amniotic fluid produced primarily by placenta, then by fetal urine

    • Amniotic sac may rupture during labor (gross rupture or small leak)

Fetal Growth and Development (1 of 3)

  • Rapid fetal growth and development characterize gestation

  • Terms

    • An developing ovum is called an embryo during the first 88 weeks

    • After 88 weeks, the developing ovum is called a fetus

    • Gestation is the period during which the fetus grows within the uterus

  • Duration and structure

    • Averages 4040 weeks from fertilization to delivery

    • Divided into trimesters

    • Estimated date of confinement (EDC/EDD)

Fetal Growth and Development (2 of 3)

  • BOX 45-1 Embryo and Fetal Development in Utero for Each Lunar Month (28 Days)

    • First Lunar Month

    • Foundations form for nervous system, genitourinary system, skin, bones, and lungs

    • Buds of arms and legs begin to form

    • Rudiments of eyes, ears, and nose appear

    • Second Lunar Month

    • Head is disproportionately large due to brain development

    • Sex differentiation begins

    • Centers of bones begin to ossify

    • Third Lunar Month

    • Fingers and toes distinct

    • Placenta is complete

    • Fetal circulation is complete

    • Fourth Lunar Month

    • Sex is differentiated

    • Rudimentary kidneys secrete urine

    • Heartbeat is present

    • Nasal septum and palate close

    • Fifth Lunar Month

    • Fetal movements felt by the mother

    • Heart sounds perceptible by auscultation

    • Sixth Lunar Month

    • Skin wrinkled; eyebrows and fingernails develop

    • Seventh Lunar Month

    • Skin red; pupillary membrane disappears from eyes

    • Eighth Lunar Month

    • Fetus viable if born; eyelids open; fingerprints set; vigorous fetal movement

    • Ninth Lunar Month

    • Face/body loose, wrinkled due to subcutaneous fat; amniotic fluid decreases slightly

    • Tenth Lunar Month

    • Skin smooth; eyes slate colored; skull bones ossified and near together at sutures

Fetal Growth and Development (3 of 3)

  • Credits/illustrations

    • © Various sources credited for imagery

Newborn Adaptations After Birth (1 of 2)

  • Newborn must adapt after placental separation

  • Fetal circulation changes to allow adequate blood flow through lungs

  • Newborn usually begins to breathe spontaneously at birth

  • First breaths are powerful to open alveoli

Newborn Adaptations After Birth (2 of 2)

  • Circulatory changes at birth

    • Ductus venosus, ductus arteriosus, and foramen ovale close as placental blood flow ceases and lungs expand

    • Systemic vascular resistance increases; aorta pressure rises; pulmonary resistance drops

    • Arteriovenous shunts close

Pregnancy Terminology (GTPAL)

  • Describing pregnant patients by gravida and para

  • GTPAL acronym

    • Gravida — number of times a person has been pregnant

    • Term — number of term deliveries

    • Preterm — number of preterm deliveries

    • Abortions — number of spontaneous or induced abortions

    • Living — number of living children

  • Para refers to number of infants born after 2020 weeks' gestation

Maternal Changes During Pregnancy (1 of 8)

  • Genital tract and uterus

    • Uterus grows from 70 g (extnongravid)70\ g\ ( ext{nongravid}) to 1000 g1000\ g by term

    • Triples in size and weight by 88 weeks

    • Occupies entire pelvic cavity and becomes an abdominal organ

    • Fundus reaches umbilicus by 2020 weeks; descends slightly near term (38–40 weeks)

    • Cervix may soften and appear blue due to increased uterine blood volume and lymphatic fluid causing pelvic congestion and edema

Maternal Changes During Pregnancy (2 of 8)

  • Genital tract (cont.)

    • Vagina develops violet color from increased vascularity

    • Vaginal mucosa thickens; vaginal secretions increase

    • Vaginal pH decreases to about 3.53.5

  • Bladder

    • Frequency of urination increases due to expanding uterus

    • Smooth muscle relaxation of ureters increases risk for urinary tract infection

Maternal Changes During Pregnancy (3 of 8)

  • Breasts

    • Tender in early weeks; increase in size by second month

    • Nipples enlarge and become more pigmented

    • Proliferation of breast glands may cause clear secretion by 10thweek10^{th} week if stimulated

Maternal Changes During Pregnancy (4 of 8)

  • Gastrointestinal system

    • Nausea and vomiting early in pregnancy (morning sickness); can occur any time of day

    • Usually begins by 66th week and abates by 1414th week

    • May relate to high serum levels of chorionic gonadotropin in early pregnancy

    • Uterus displaces stomach and intestines, causing indigestion and reflux

    • Liver displaced backward, upward, and to the right

    • Decreased GI tone and motility → prolonged gastric emptying and pyloric sphincter relaxation

Maternal Changes During Pregnancy (5 of 8)

  • Cardiovascular system—heart

    • Diaphragm elevation displaces heart left/upward

    • ECG may show flat ST segments or negative T waves; possible left axis deviation

    • Dysrhythmias: SVT, atrial fibrillation/flutter, rare VT

    • Cardiac output increases by 30%30\% by 34th34^{th} week

    • Pulse rate may increase by 15$-$20\ beats/min late in 3rd trimester

    • Pulmonic and apical murmurs common due to reduced viscosity and turbulence

Maternal Changes During Pregnancy (6 of 8)

  • Cardiovascular system—circulation

    • Total blood volume increases by 30%30\%; plasma by 50%50\%

    • Blood pressure decreases 10−15 mmHg10-15\ mmHg during 2nd trimester due to reduced peripheral resistance

    • Gradually returns to pre-pregnancy levels toward term

    • Enlarged uterus may cause venous return issues: peripheral edema, hemorrhoids, varicose veins

    • Supine position can cause inferior vena cava compression, reducing venous return

Maternal Changes During Pregnancy (7 of 8)

  • Respiratory system

    • Tidal volume and minute ventilation increase by 30\%$-$40\% in late pregnancy

    • Functional residual capacity decreases by  25%~25\%

    • Oxygen consumption increases by 30\%$-$60\%

    • Respiratory rate normal or increased due to diaphragm elevation

    • PCO2 normally decreases from 40 mmHg40\ mmHg to about 30 mmHg30\ mmHg; creates gradient for fetal CO2 clearance

    • May cause dizziness or shortness of breath

Maternal Changes During Pregnancy (8 of 8)

  • Metabolism

    • Recommended weight gain ranges based on prepregnant BMI

    • Increased water retention raises hydrostatic pressmaternal cure → edema

    • Metabolic rate and caloric demand (protein) increase

    • Glucose can spill into urine due to increased glomerular filtration

    • Gestational diabetes mellitus (GDM) may result from impaired carbohydrate metabolism

    • Fetal demands for calcium and iron may deplete maternal stores without adequate diet/supplementation

Patient History (1 of 2)

  • Determine chief complaint; may not be related to pregnancy

  • Obstetric history includes:

    • Length of gestation

    • Parity and gravidity

    • Prior cesarean delivery

    • Maternal lifestyle (alcohol/drug use, smoking)

    • Infectious disease status

    • History of gynecologic/obstetric complications

Patient History (2 of 2)

  • Details on onset of signs and symptoms

    • Presence of pain: onset, character, duration/evolution, location/radiation

    • Vaginal bleeding

    • Abnormal vaginal discharge

    • Presence of “show” or rupture of membranes

    • Current general health and prenatal care

    • Allergies and medications

    • Maternal urge to bear down (imminent delivery)

Physical Examination (1 of 6)

  • Primary goal: rapidly identify acute life-threatening conditions

  • Assess general appearance and skin color for signs of hemorrhage or dehydration

  • Monitor vital signs; normal physiologic changes can alter vitals

  • Examine abdomen for scars and gross deformities

  • Assess for peritoneal irritation (tenderness, guarding, rebound)

Physical Examination (2 of 6)

  • Evaluating uterine size and growth

    • Irregular contour between 8−108-10 weeks

    • Above symphysis pubis at 12−1612-16 weeks

    • At level of the umbilicus at 2020 weeks

    • Near xiphoid process at term

Physical Examination (3 of 6)

  • Fetal distress monitoring

    • Fetal heart sounds via Doppler starting at 1212 weeks

    • To assess fetal well-being, place Doppler below the umbilicus on the fetal back side

    • Normal fetal heart rate: 120−160 extbeats/min120-160\ ext{beats/min}

    • Fetal tachycardia: >160 extbeats/min160\ ext{beats/min}; fetal bradycardia: <110 extbeats/min110\ ext{beats/min}

Physical Examination (4 of 6)

  • Continued fetal distress monitoring

    • If fetal rate remains outside normal range for >60 extseconds60\ ext{seconds}, may indicate distress or hypoxia

    • Short-term fluctuations during fetal sleep, movement, or contractions are common

Physical Examination (5 of 6)

  • Causes of fetal distress to consider

    • Fetal anemia

    • Oligohydramnios (low amniotic fluid)

    • Pregnancy-induced hypertension

    • Postterm pregnancy (4242 weeks or more)

    • Intrauterine growth restriction

    • Meconium-stained amniotic fluid

Physical Examination (6 of 6)

  • MEOWS: Modified Early Obstetric Warning System

    • Tool to predict complications from 2020 weeks gestation to 66 weeks postpartum

General Care for the Obstetric Patient

  • If birth is not imminent, provide basic supportive care only: airway, ventilation, circulation

  • Transport in a comfortable position if no distress or injury

  • Preferred position: left lateral recumbent

Complications of Pregnancy

  • Categories: Antepartum (before childbirth), Intrapartum (labor/delivery), Postpartum (after childbirth)

Hyperemesis Gravidarum (1 of 3)

  • Symptoms: severe nausea, vomiting, weight loss, ketosis, electrolyte disturbances (e.g., hypokalemia)

  • HG in prior pregnancies often recurs with similar pattern

  • Onset: within 22–55 weeks after conception

  • Usually eases after first trimester; may persist to delivery in 10%−20%10\%-20\% of mothers

Hyperemesis Gravidarum (2 of 3)

  • Causes (multiple factors)

    • Pregnancy hormone imbalances

    • Vitamin B deficiency, hyperthyroidism

    • GERD with electrical abnormalities affecting stomach muscles

    • Helicobacter pylori infection

    • Psychological factors

    • Disturbances in carbohydrate metabolism

Hyperemesis Gravidarum (3 of 3)

  • Management

    • Antiemetics to control nausea/vomiting

    • Rehydration and electrolyte replacement

    • Severe cases: hospitalization and IV fluids

Rh Sensitization (1 of 4)

  • Rh status concepts

    • Rh-negative individuals lack Rh marker on red blood cells; Rh-positive individuals have the marker

  • Sensitization risk

    • Occurs during pregnancy if an Rh-negative mother carries an Rh-positive fetus; maternal antibodies can destroy fetal RBCs in subsequent pregnancies

  • First pregnancy generally not affected due to lack of exposure, but exposure can occur at delivery

Rh Sensitization (2 of 4)

  • Screening and prevention

    • Early pregnancy testing for Rh factor

    • Rh-negative but not sensitized individuals require antibody testing until delivery; newborn will be tested at birth

    • Rh immune globulin (e.g., RhoGAM) given to prevent sensitization

    • One injection at 26−28 week26-28\ weeks

    • Second injection within 72 hours72\ hours of birth if the child is Rh-positive

Rh Sensitization (3 of 4)

  • If sensitized, monitoring and testing required

    • Serial blood tests for mother/fetus

    • Fetus may require Doppler and amniocentesis monitoring

    • In severe fetal anemia: possible fetal/neonatal transfusions

    • Early cesarean delivery can be common

Rh Sensitization (4 of 4)

  • Rh disease in newborns

    • Some show no symptoms; others can have erythroblastosis fetalis

    • Two main forms: ABO incompatibility (most common) and Rh incompatibility

    • Symptoms: anemia, jaundice, edema, hepatosplenomegaly, hydrops fetalis

    • Treatment: blood transfusion

Gestational Diabetes Mellitus (1 of 3)

  • Diabetes caused by pregnancy

  • May result from insulin deficiency or placental hormone interference with insulin action

  • Treatment: regular glucose monitoring, dietary modification, exercise, insulin injections in some cases

Gestational Diabetes Mellitus (2 of 3)

  • Most patients are identified during prenatal care and have healthy pregnancies

  • Risks if untreated: very large baby, difficult labor/delivery with higher risk for fetal/maternal injury, longer recovery

Gestational Diabetes Mellitus (3 of 3)

  • Risks for offspring

    • Increased risk of respiratory distress syndrome, obesity, type 2 diabetes later in life

  • Management

    • Glucose testing, hypoglycemia management with IV dextrose, or hyperglycemia management with IV fluids and insulin

Infection

  • TORCH infections and other infections can affect pregnancy and fetus

  • TORCH: toxoplasmosis, other agents, rubella, cytomegalovirus, herpes simplex

  • Infections can pass through the placenta and cause fetal death or serious newborn complications

  • Prevention: immunization, good hygiene, safe sex practices

Pulmonary Embolism

  • PE is a significant cause of maternal death

  • Key risk factors: venous stasis, hypercoagulability, vascular injury

  • Classic signs: sudden dyspnea, chest pain, tachycardia, tachypnea, crackles, hemoptysis; may cause hypotension

Premature Rupture of Membranes (PROM)

  • Rupture of amniotic sac before labor begins

  • Preterm PROM (PPROM) if fetal age <37 weeks37\ weeks

  • Fetus at risk before 34 weeks34\ weeks

  • Occurs in about 8%8\% of pregnancies; 10–15% near term

  • Signs: history of vaginal gush or trickle of fluid

  • If infection diagnosed (chorioamnionitis), delivery is required

  • Infection more likely if >24 hours24\ hours since PROM

Bleeding Complications Related to Pregnancy (1 of 6)

  • Spontaneous abortion (miscarriage)

    • Noninduced termination before 20 weeks20\ weeks

    • Most frequent vaginal bleeding in pregnancy; occurs in 10−26%10-26\% of clinically recognized pregnancies

  • History and management

    • Time and onset of pain/bleeding, amount of blood loss, passage of clots/tissue

    • Management includes close observation for significant blood loss and hypovolemia, emotional support, transport for physician evaluation

Bleeding Complications Related to Pregnancy (2 of 6)

  • Ectopic pregnancy

    • Implantation outside the uterus (1–2% of pregnancies); leading first-trimester death and contributes to maternal deaths

    • Predisposing factors: PID, adhesions from prior surgery, tubal ligation, prior ectopic, possibly IUD

  • Triad of symptoms: abdominal pain, vaginal bleeding, amenorrhea

  • Other symptoms: referred shoulder pain, early pregnancy signs

  • Management: treat for shock and rapid transport

Bleeding Complications Related to Pregnancy (3 of 6)

  • Third-trimester bleeding — abruptio placentae

    • Partial or full detachment of placenta after 20 weeks

    • Predisposing factors: hypertension, preeclampsia, multiple gestation, smoking, trauma, previous abruption, cocaine/meth use

    • Most common presentation: sudden third-trimester vaginal bleeding and pain

Bleeding Complications Related to Pregnancy (4 of 6)

  • Third-trimester bleeding — placenta previa

    • Placental implantation in lower uterine segment covering cervical opening

    • Results in painless vaginal bleeding with bright red blood

    • Risk factors: prior cesarean, advanced maternal age, multiple gestation, cocaine use, prior placenta previa

Bleeding Complications Related to Pregnancy (5 of 6)

  • Third-trimester bleeding — uterine rupture

    • Often from reopening of prior scar or prolonged labor

    • Signs: active labor with sudden abdominal pain and signs of shock; vaginal bleeding may be absent or minimal

    • Delivery needed in less than 37 minutes to prevent serious complications

    • Maternal hemorrhage risk; manage to prevent shock and transport

Bleeding Complications Related to Pregnancy (6 of 6)

  • Overall management goals

    • Prevent shock; rapid transport; monitor mother and fetus; document bleeding amount and color; collect expelled tissue

Labor and Delivery (1 of 11)

  • Parturition is the process by which the fetus is born

Labor and Delivery (2 of 11)

  • Stages of labor

    • Stage duration varies with parity (first pregnancy vs. previous deliveries)

Labor and Delivery (3 of 11)

  • Signs and symptoms of imminent delivery

    • Regular contractions 45–60 seconds, 1–2 minute intervals

    • Urge to bear down or bowel movement

    • Bloody show

    • Crowning

    • Belief that delivery is imminent

Labor and Delivery (4 of 11)

  • Preparation for delivery

    • Position the mother on a bed, stretcher, or table

    • Back-lying with knees flexed and apart or alternative patient-preferred position

    • Coach to bear down during contractions and rest between

    • If prone to push, encourage deep breathing or panting between contractions

Labor and Delivery (5 of 11)

  • Prehospital delivery equipment (OB kit)

    • Scissors, cord clamps/umbilical tape, towels, masks, gauze sponges, sanitary napkins

    • Meconium suction kit, baby blanket and cap, plastic bag for placental transport

    • Neonatal resuscitation equipment, IV fluids

Labor and Delivery (6 of 11)

  • Assistance with delivery (1)

    • Observe standard precautions

    • At crowning, apply gentle palm counterpressure to fetal head to prevent explosive delivery and tearing

    • Tear membranes if still intact via finger pressure

    • After head delivery, check for looped umbilical cord; support head as it rotates for shoulder presentation

Labor and Delivery (7 of 11)

  • Assistance with delivery (2)

    • Gently guide head downward to deliver anterior shoulder, then upward to release posterior shoulder

    • Remaining baby delivered quickly by uterine contraction

    • Support newborn on mother's abdomen if possible

    • Clear airway with sterile gauze if secretions obstruct

    • Dry newborn with sterile towels and cover head; place on mother’s chest for skin-to-skin if stable

    • Routine suctioning of mouth and then nose only if airway obstruction

    • Record sex and time of birth

    • Clamp umbilical cord after 1 minute; ensure newborn not placed higher than mother to prevent backflow

Labor and Delivery (8 of 11)

  • Assistance with delivery (3)

    • Continue skin-to-skin, dry newborns and maintain warmth

    • Monitor for breathing, tone, and activity

    • Perform Apgar scoring (Table 45-3 below) at 1 and 5 minutes

Labor and Delivery (9 of 11)

  • The Apgar Scoring System (Table 45-3)

    • Appearance (skin color): 0 = blue/pale; 1 = body pink, extremities blue; 2 = completely pink

    • Pulse rate: 0 = Absent; 1 = <100 beats/min; 2 = >100 beats/min

    • Grimace (irritability): 0 = No response; 1 = grimace; 2 = cough/sneeze/cry

    • Activity (muscle tone): 0 = Limp; 1 = some flexion; 2 = active motion

    • Respirations: 0 = Absent; 1 = slow/irregular; 2 = good crying

    • Typical scoring interpretation: higher scores indicate better status; scores used to guide initial care

Labor and Delivery (10 of 11)

  • Cutting the umbilical cord

    • After baby is evaluated and cord stops pulsing, clamp and cut

    • Delay until after baby is on mother and breathing well for 30 seconds to 1 minute

    • Clamp about 4–6 inches from newborn in two places; cut between clamps with sterile scissors/scalpel

Labor and Delivery (11 of 11)

  • Delivery of the placenta

    • Usually delivers within 20 extminutes20\ ext{minutes} after newborn delivery

    • Do not wait for placenta to deliver before transport

    • Uterus rises and feels hard; cord protrudes and blood gushes from vagina

    • Instruct patient to bear down to expel placenta; place placenta in plastic bag

    • Inspect perineum for lacerations and apply pressure to bleeding areas

    • Initiate fundal massage; monitor for hemorrhage or shock during transport

Delivery Complications (1 of 13)

  • Cephalopelvic disproportion

    • Fetal head too large or maternal birth canal too small for normal labor

    • Prehospital care limited to maternal oxygen, IV access, rapid transport

Delivery Complications (2 of 13)

  • Abnormal presentation—shoulder dystocia

    • Fetal shoulders wedged against maternal symphysis pubis

    • Complications: brachial plexus damage, clavicle fracture, fetal anoxia from cord compression

    • Management: position supine with hips hyperflexed; apply suprapubic pressure; avoid fundal pressure; attempt to guide head downward

Delivery Complications (3 of 13)

  • Abnormal presentation—shoulder dystocia (cont.)

    • If unsuccessful, turn patient to all-fours to allow posterior shoulder to descend

    • On-scene physician maneuvers: Woods corkscrew or reverse corkscrew; manual delivery of posterior shoulder

Delivery Complications (4 of 13)

  • Abnormal presentation—breech presentation

    • Largest fetal part (head) delivered last

    • Breech types: Frank (hips flexed, knees extended), Complete (hips/knees flexed), Incomplete (hips/knees extended, one or both feet first)

Delivery Complications (5 of 13)

  • Abnormal presentation—breech (cont.)

    • If breech is present with no visible fetus or only legs/buttocks visible: do not push; rapid transport; call for assistance; administer oxygen; place hand in vagina to prevent delivery

Delivery Complications (6 of 13)

  • Delivery Complications (imminent delivery with breech not transportable)

    • Place patient supine and allow buttocks/feet to deliver; do not assist until fetal umbilicus visible

    • Support body as head delivers; consider kneeling position for mother; assess for prolapsed cord

    • If head not delivering promptly, insert gloved hand to create an airway; form a V with fingers to tilt chin toward chest; rotate trunk as needed

    • Do not pull on trunk or presenting part; support as mother pushes

Delivery Complications (7 of 13)

  • Internal obstetric maneuvers (possible for OBs on scene)

    • Pinard maneuver: rotate fetal thigh/pelvis to aid delivery

    • Mauriceau maneuver: keep fetal head flexed for delivery

    • Zavanelli maneuver: push fetal head back into birth canal

Delivery Complications (8 of 13)

  • Abnormal presentation—shoulder presentation

    • Transverse presentation; labor typically not normal

Delivery Complications (9 of 13)

  • Abnormal presentation—umbilical cord prolapse

    • Cord passes through cervix before fetus and can be compressed

    • Risk of fetal asphyxia; reposition newborn safely and transport urgently

    • Position mother with hips elevated; administer oxygen; cover exposed cord with moist sterile dressings; prepare for panting to avoid bearing down

Delivery Complications (10 of 13)

  • Abnormal presentation—other abnormal presentations

    • Face or brow (military) presentation and occiput posterior presentation

    • Increased fetal risk; emphasize early recognition, maternal support, reassurance, rapid transport

Delivery Complications (11 of 13)

  • Premature birth

    • Born before 37 weeks37\ weeks; low birth weight < 5.5 lb5.5\ lb (2.5 kg)

    • Increased risk for hypothermia and cardiorespiratory distress

    • Care: keep warm and dry, suction secretions, monitor cord end, humidified oxygen, transport

    • Tocolytic agents may be used for mothers at risk of preterm birth

Delivery Complications (12 of 13)

  • Multiple gestation

    • More than one fetus

    • First twin delivery similar to singleton with same presentation

    • Clamp/cut first newborn’s cord after delivery; second newborns typically birth within 30−45 extmin30-45\ ext{min}; contractions start 5−10 extmin5-10\ ext{min} after first birth

    • Newborns in multiples are often smaller; keep warm and well oxygenated

Delivery Complications (13 of 13)

  • Uterine inversion

    • Uterus turns inside out; associated with excessive pulling on cord and fundal massage

    • Severity: incomplete, complete, prolapsed inversion

    • Signs: postpartum hemorrhage, severe abdominal pain

    • Management: place patient supine; do not attempt placenta removal; push fundus upward through cervical canal; if ineffective, cover protruding tissues and transport rapidly

Postpartum Care: Postpartum Hemorrhage (1 of 3)

  • Defined as >500 mL500\ mL blood loss after delivery within the first 24 hours24\ hours (primary hemorrhage); may occur later

  • Causes: ineffective uterine contraction, retained placental tissue, vaginal/cervical tears

Postpartum Care: Postpartum Hemorrhage (2 of 3)

  • Risk factors for uterine atony

    • Prolonged/tumultuous labor, grand multiparity, twin pregnancy, placenta previa, full bladder

Postpartum Care: Postpartum Hemorrhage (3 of 3)

  • Management

    • Massage uterus until firm

    • Encourage breastfeeding

    • Per medical direction: add 10 units10\ units of oxytocin to IV (1000 mL) and infuse 20–30 mL/min

    • Continue fluid resuscitation; transfuse blood products

    • Consider tranexamic acid

Amniotic Fluid Embolism

  • Amniotic fluid can enter maternal circulation during labor/delivery via cervical veins, lower uterine segment, or uterine trauma

  • Extremely rare but high maternal mortality

  • Risk factors: multiparous, late in first stage, placenta previa, abruptio placenta, intrauterine fetal death

  • Signs mirror pulmonary embolism: dyspnea, chest pain, hypoxia, hypotension

Postpartum Depression (1 of 3)

  • Affects 1 in 71\ in\ 7 mothers

  • Symptoms last at least 2 weeks2\ weeks, beginning during pregnancy or within 4 weeks4\ weeks of childbirth

  • Signs: appetite/weight and sleep changes, decreased energy, feelings of worthlessness/guilt, difficulty thinking, suicidal ideation

Postpartum Depression (2 of 3)

  • Risk factors

    • Adverse socioeconomic conditions, history of depression, complicated pregnancy/delivery, fetal complications, family history of mental illness, poor marital adjustment, life stressors, lack of support

  • Recognition and treatment importance for mother and child health

Postpartum Depression (3 of 3)

  • Postpartum infection

    • Often occurs within first week after delivery

    • May include incision infection, endometritis; signs include pain, redness, drainage, fever, tachycardia, abdominal pain, foul discharge, hypotension if septic

Trauma During Pregnancy (1 of 7)

  • Maternal injury: major causes are motor vehicle crashes, interpersonal violence, falls

  • Fetus generally protected but may suffer direct penetrating wounds or significant blunt abdominal trauma

  • Severe trauma can cause abruptio placentae, preterm labor, or uterine rupture

  • Greatest risk to fetus is interruption of placental blood flow due to trauma or maternal hypotension

Trauma During Pregnancy (2 of 7)

  • Assessment and management

    • Address exsanguinating hemorrhage; ensure airway, oxygenation, ventilation, circulatory support with spinal precautions if indicated

    • Rapid stabilization and transport

    • Detect injuries contributing to hypovolemia/hypoxia; blood loss may be difficult to detect due to physiological changes in pregnancy

    • Fetal monitoring is the best indicator of fetal well-being after trauma

Trauma During Pregnancy (3 of 7)

  • Special management considerations: airway and oxygenation

    • Maintain maternal airway with adequate oxygenation to prevent fetal hypoxemia

    • Monitor with pulse oximetry; provide supplemental oxygen

Trauma During Pregnancy (4 of 7)

  • Volume replacement and hemorrhage control

    • Hypovolemia signs may be delayed; blood often shunted from uterus to preserve maternal BP

    • Crystalloid fluids for maternal hypotension; vasopressors generally not recommended

  • Vaginal bleeding considerations

    • Could indicate placental detachment, placenta previa, or uterine rupture

    • Avoid vaginal examination if bleeding heavy; document amount and color; collect expelled tissue

Trauma During Pregnancy (5 of 7)

  • Transport strategies

    • Transport in left lateral recumbent position to avoid supine hypotension unless spinal injury suspected

    • If spinal injury suspected: place on long backboard, tilt left 10°–15°, place wedge under right side to move uterus left

Trauma During Pregnancy (6 of 7)

  • Transport destination

    • Consider transport to a trauma center; major injuries should go to trauma unit/ED, not just labor and delivery

Trauma During Pregnancy (7 of 7)

  • Overall goal: protect mother and fetus; rapid transport to definitive care

Cardiac Arrest in the Pregnant Patient (1 of 3)

  • Cardiac arrest in pregnancy can have multiple causes

  • Key concept: resuscitation of the mother is essential for fetal resuscitation

Cardiac Arrest in the Pregnant Patient (2 of 3)

  • Resuscitation approach

    • Initiate high-quality chest compressions with minimal interruptions

    • Manual uterine displacement to improve venous return if it does not compromise chest compressions

    • Defibrillate for shockable rhythms using standard drug/dose protocols

Cardiac Arrest in the Pregnant Patient (3 of 3)

  • If gestational age ≥ 20 weeks20\ weeks or fundal height ≥ two fingerbreadths above the umbilicus

    • Transport for perimortem cesarean delivery as soon as possible

    • Aim to perform within 5 minutes5\ minutes of loss of maternal pulse to save life of mother and fetus

    • Perimortem cesarean delivery improves maternal circulation and fetal outcomes