EMS OBGYN OVERVIEWLYSTRA WILSON-CELESTINE, FACOGMay 21th 2015

OBJECTIVES

Review female anatomy and reproductive system

Normal pregnancy, labor and delivery

Assessing a pregnant patient

Common complications and emergencies of pregnancy

Newborn care

Review of case scenarios

Definition of Terms

Gravity: # of pregnancies

Parity: # of pregnancies >20wk

Nulliparous: never pregnant

Primagravid: first pregnancy

Definition of Terms

Presentation: leading part in birth canal-crown, rump, face, arm.

Term : 37 to 42wks.

Preterm : <37wks

Post term:>42wks

Abortus: Fetus /embryo delivered <20wk/500gm

External Genitalia

Pelvic Anatomy

Reproductive Organs

Physiology of Pregnancy

Genital Tract Vagina, perineum:

Increased vascularity, hyperemia, edema Increased secretions (thick white discharge) Acidic pH( 3.5-6) Increased vaginal wall length Chadwick’s sign- violet color of vagina/vulva

Normal cervix

Chadwick’s sign and leucorrhea

Chadwick sign- pregnant

Physiology of PregnancyUterus

500-1000 fold increase in size

Wt. at term +/- 1100gm

Out of pelvis by end of 12th wk.

Dextrorotated

Blood flow increases from 100 to 650ml/min

Limited auto regulation

Physiology of PregnancyUterus

Limited Auto regulation Maximum uterine vessel dilation leave little auto regulation

to improve flow during perfusion pressure changes Decreased maternal cardiac output blood flow shift away

from placenta to maternal brain, kidney and heart.

Uterine Hypertrophy Venous compression fall in venous return, fall in cardiac

output Compensation: Supine hypotension syndrome, nausea,

dizziness, syncope, relief by position change

Physiology of PregnancyCervix

Thickened mucus

Chadwick sign

Eversion of columnar cervical glands

Physiology of PregnancyOvaries

Suspended follicular maturation

Enlarged ovarian veins

Single corpus luteum Functional 4-5wks post ovulation Produces progesterone, relaxin

Physiology of PregnancySkin

Vascular Spider angiomas Palmar erythema- also seen thyroid disease,

lung CA or inherited

Striae gravidarum Genetic disposition

Palmar erythema

Spider Angioma

Striae gravidarum

Physiology of PregnancySkin

Increased pigmentations due to estrogen, progesterone, melanocytes simulating hormones Linea negra Chloasma/Melasma gravidarum

Linear Negra

Molasma Gravidarum

Physiology of PregnancyBreast

Tender/tingling sensation in early preg

Nipple enlarges, broader areolae with increased pigmentation

Increase size from ductal growth and alveolar hyperplasia

Colostrum production

Physiology of PregnancyMusculoskeletal

Lumbra lordosis low back pain

Relaxation of pubic symphysis and sacroiliac joints

Relaxed muscles leading to hernia and easily strained muscles

All compounded by weight gain.

Lordosis of pregnancy

Physiology of PregnancyHematologic

50% increases in blood volumePlasma volume increases 50-70%; starts at

6wksRBC mass increase 20-35%: starts at 12wk

Physiologic anemiaHemodilutionalAnemia nadirs at 30-34wks

Physiology of PregnancyHematology

Iron Deficiency Anemia Increased iron requirements, supplements

recommended term Hgb <10mg/dL due to deficiency rather

than hemodilution

Immune changes WBC increases to 6000-16000 in 3rd TM Plt decrease slightly

Physiology of PregnancyHematology

Coagulation Fibrinogen increases 50% Changes in clotting factors and regulatory

protein

Cardiac output Begins to increase by 5th wk Peaks at 20-24wks Rises by 40% by 20-24wks Overall 50% increase

Physiology of PregnancyHematology

Initially increase in heart rate

Reduced systemic vascular resistance

CXR: displaced heart to left upward and pericardial effusion

Physiology of PregnancyTest Interpretation

BP: SBP increases by 5-10mmHg; DBP by 10-15mmHg (before 24wks). Each contraction pushes 300-500ml from

uterus to circulation Rise in arterial BP 10mmHg during Ctx.

Physiology of PregnancyRespiratory

Estrogen hyperemic, edematous nasopharynx and increased mucous secretions. Symptoms: stuffiness, epistaxis, chronic cold.

chest circum. and transverse diameter; Diaphragm pushed up 4cm Changes in lung volumes and pulmonary function test.

Oxygen consumption increases 15-20%

BOTTOM LINE

State of hyperventilation with chronic respiratory alkalosis

Physiology of PregnancyUrinary

• Mechanical Ureteric obstruction from uterus Incomplete bladder empting Vesicoureteral reflux

• Physiology 75% renal blood flow with increase in GFR 50% Multiple trips to bathroom Glucosuria, Proteinuria

Physiology of PregnancyGastrointestinal

Increased appetite (300kcal/d)

Ptyalism (1-2L/d) spitting

Gingivitis

Lower tone of Gastroesophageal sphincterreflux

Delay gastric emptying (60% of meal emptied in 90mins for non-pregnant; doubled time for pregnant)

Physiology of PregnancyGastrointestinal

Increased small bowel transit time 58 vs 52hrs

Stomach and intestinal displacement appendix at right flank

Constipation/Hemorrhoids

Gallbladder changes increased risk of stones

Normal Pregnancy Events

1st Trimester (LMP to 13wks) Nausea/Vomiting, fatigue, Food aversion or

cravings, spotting, breast tenderness, increased sex drive

Gain about 5-8lbs Complications- Miscarriage, Ectopic, blighted

ovum

Normal Pregnancy Events

• 2nd Trimester (13-26wks) Feeling of well being, less fatigue. Round ligament pain, bladder pressure, round

ligament pain, Braxton hicks Complications- fetal loss is minimal but can seen

with labor, incompetent cervix, intrauterine death.

Normal Pregnancy Events

• 3rd Trimester (26wks to delivery) Feeling uncomfortable; pelvic/back pain and

pressure Lower extremities swelling, varicosities,

engagement, contractions,. Wt gain 1lbs/wk Complications: Rupture membranes, preterm

labor, pregnancy induced hypertension, Urinary tract infection, Gestational diabetes

Complications of Pregnancy

Vaginal bleeding

Spontaneous Miscarriage

Ectopic Pregnancy

Premature rupture of membranes with cord prolapse

Pre eclampsia/Eclampsia

Placental Previa

Complications of Pregnancy

Medical/surgical eg diabetes, ruptured appendix

Abruptio Placenta

Breech presentation and delivery

Meconium Stained fluid

Abnormal labor pattern

Stressed Newborn

Labor

Clinical diagnosis

Onset of regular rhythmic contractions

Progressive cervical dilation and effacement

3 stages

Stages of Labor

Stage 1 Interval between labor onset and full cervical

dilation Latent phase- period btw labor onset to start of

rapid change of cervical dilation Active phase- period from 6cm to 10cm

Stages of Labor

Stage 2 Interval btw full dilation (10cm) to delivery of

infant Nulliparous- push for max of 2hr without regional

anesthesia(3hr with) Multiparous- push for max 1hr without anesthesia

(2hr with)

Stages of Labor

Stage 3 Refers to delivery of placenta and fetal

membranes Make take up to 30mins What are the active interventions if >30mins?

Cardinal Movementof Labor

Engagement- passage to widest diameter of presenting part below plan of pelvic inlet

Descent- downward passage of presenting part through pelvis

Flexion- passive flexion of head on to chest

Cardinal Movements of Labor

Internal Rotation- vertex moves from transverse to anteroposterior position

Extension – fetus head is at level of introitus; base of occiput is at inferior margin of pubic symphysis

External Rotation- or restitution- return of head to correct anatomical position- LOA or ROA

Explusion- delivery of rest of fetus

Demonstration of Delivery Method.

https://www.youtube.com/watch?v=ZDP_ewMDxCo

Field Obstetric Assessment

Determine if delivery is imminent

Remain calm

Ask few questions Closed ended Simple answers

Perform visual exam (with permission)

Evaluate vitals

Obstetrics Assessment

Things you want to know Due date Number of pregnancies delivered in past Length of labor in past Is there vaginal bleeding or did she break her

water Is there a feelings to have a bowel movement

Obstetrics Assessment

If delivery is imminent- What are the signs? Crowning or bulging She screams “I need to take a dump “or “its

coming” or “I have to push”

What to do! Remain calm, place patient supine in safe location. Disrobe undergarment – have pt/husband/ SO do it. Visual check of perineum- blood loss, fetal parts,

bag Abdominal palpation for contractions-duration,

interval

Obstetrics AssessmentField Delivery

Anticipate exposure of large amount of blood and body fluids

Full personal protection is recommended

Don’t assume absence or presence of disease by appearance of patient or situation.

Sterile OB Kit Content

Sterile exam gloves

Disposable scalpel

Maternity pad

Plastic lined under pad

Receiving blanket

Disposable towels

Gauze sponges

Disposable bulb syringe

Disposable plastic apron

Plastic bag to hold placenta

Twist ties

O.B. towelettes

Umbilical cord clamp

Obstetrics AssessmentField Delivery

You are ready for a delivery!!!

Crowning/Extension

External Rotation

External Rotation

Delivery of Anterior Shoulder

Delivery of Posterior Shoulder

Double cord clamping and cutting

Case Scenario #1

Case Scenario #1

Post partum hemorrhage risk factors: Grand multiparous, rapid labor, prolonged

labor, augmented labor History of postpartum hemorrhage,

episiotomy, especially mediolateral, preeclampsia,

Overdistended uterus (macrosomia, twins, hydramnios), operative delivery, Asian or Hispanic ethnicity, chorioamnionitis

Case Scenario #2

Case Scenario #2

Cord Prolapse True emergency Need to release pressure of head against cord Sterile vaginal exam check for cord pulsation

and push up on vertex. Keep hand in vagina until OB team takes over. Emergency cesarean section with general

anesthesia is fastest way to deliver.

Case Scenario #2

Case Scenario #3

Case Scenario #3

Abruptio Placenta Premature separation of normal placenta from

uterine wall secondary to decidual bleeding. 1/86 to 1/206 cases. Risks factors:

Hypertensive disease, Advanced maternal age and parity Drug use (eg smoking, cocaine) Trauma Uterine anomalies eg fibroids Sudden decompression eg ROM

Placental Abruption

Case Scenario #3

Abruptio Placenta Classic Signs: vaginal bleeding, abdominal pain,

uterine contractions and tenderness Abruption can be concealed with no evidence of

vaginal bleeding (10-20%) Size of hemorrhage predictive of fetal survival

>60ml associated with >50% fetal mortality.

Case Scenario #4

Case Scenario #4

Neonatal Resuscitation Assessing a Newborn- 3 questions!!

Is the baby term? Is the baby breathing or crying? Is the baby moving with good tone or is it flaccid?

If YES to all, then Clamp and cut cord 7-8 inches from insertion site Place baby with mom Provide warmth, dry baby’s skin Record APGAR

Case Scenario #4

Case Scenario #4

Neonatal Resuscitation If NO to any of the 3 questions, then

Provide warmth Clear airways if necessary Stimulate baby

Check HR: if <100- assist ventilation with bag valve mask

Check breathing: if labored or cyanotic- clear airway

Re evaluate HR and breathing after intervention

Case Scenario #4

Neonatal Resuscitation If HR <60 start compression Revaluate HR and breathing. If no change

consider intubation (hopefully you are in the ER dept)

Establish access: umbilical vessels, IV, IO Medication use if condition deteriorates Consider possible narcotic use in mom- narcan

for reversal. Pneumothorax, anomalies, cardiac or

respiratory defects, blood sugar etc.

Case Scenario #5

Case Scenario #5

Ectopic pregnancy Implantation of fertilized ovum outside uterine

cavity 2% of all pregnancies in USA Most common cause of maternal mortality in 1st

trimester

Case Scenario #5

Ectopic Pregnancy- Risk Factors Prior ectopic (15-5%) Tubal surgery (15-20%) Tubal pathology (90%) PID history (6-9%) Infertility (5%) Sterilization (33%)

Case Scenario #5

Ectopic pregnancy Locations:

Tubal 96% Ovarian <1% Cervical<1% Abdominal 1.3%

Case Scenario #5

Ectopic Pregnancy Signs

Abdominal tenderness 91% 1st TM bleeding 79% Tachycardia, low grade fever Cervical motion tenderness Tender pelvic or adnexal mass Chadwick sign Hypoactive bowel sound

Case Scenario #5

Ectopic Pregnancy- Symptoms Onset about 6-7wks after LMP Pelvic pain Vaginal bleeding N/V/D and dizziness

Differential Diagnosis Appendicitis Threatened abortion Ruptured ovarian cyst

Case Scenario #5

Ectopic pregnancy- Differential Diagnosis PID Endometritis Kidney stones Normal pregnancy UTI

Diagnosis Beta HCG levels Ultrasound

Case Scenario #5

Ectopic Pregnancy Treatment

Expectant management Medical- Methotrexate( anti metabolite) Surgical

Case Scenario #6

Case Scenario #6

Preeclampsia- eclampsia Form of hypertensive pregnancy specific

disorder that occurs after 20wks Characterized by vasospasm, coagulation

system activation, hyperreflexia Multitude of Symptoms Categorized: mild vs. severe preeclampsia

Case Scenario #6

Preeclampsia-eclampsia Mild pre eclampsia

BP >140/90 +1 urine dip protein or >300mg on 24hrs

Severe Preeclampsia BP >160/110 Proteinuria >5g or 3-4+ urine dip Cerebral and visual disturbance Epigastric pain Pulmonary Edema

Case Scenario #6

Preeclampsia-eclampsia Eclampsia Elevated liver enzymes HELLP

Cause unknown; possible abnormal placentation or endothelial activation

Prevention – no proven therapy Low ASA Calcium Antioxidant eg Vit A

Case Scenario #6

Preeclampsia-eclampsia Delivery is ONLY known treatment Vaginal delivery unless otherwise indicated Delivery based on gestational age and severity

of disease.

Treatment Eclamptic Seizure prophylaxis/treatment-

Magnesium sulfate IV Antihypertensive therapy SBP >160-180 DBP

>110

Case Scenario #6

Preeclampsia-eclampsia

Treatment Monitor coagulation factors and LFTs Aggressive fluid management, risk of

pulmonary edema Monitor urine output

Postpartum Continue Mg SO4 for 24hrs BP control, 40% recurrence rate.