AEMCA - Obstetrics Flashcards
How much does blood volume increase during pregnancy?
30%
- To compensate for increased renal and uterine blood flow
- This allows to oxygenate/remove waste for fetus
- Increased volume also causes peripheral edema (due to higher pressure gradient)
What supplement is recommended in pregnancy?
Iron
- To compensate for low hemoglobin
- Due to increased blood and plasma volume (anemia)
When does blood pressure decrease during pregnancy? How much does it decrease by? And why does it decrease?
2nd Trimester (around 13-26 weeks)
- BP decreases by 10-15 mmHg (normally returns to normal by third trimester)
- As blood volume increases, blood vessels dilate in response.
- Hormonal changes (such as increased production of progesterone and estrogen) can also cause vasodilation
How much does pulse rate increase during pregnancy, and when specifically does it increase?
Pulse rate increases 15-20 BPM above patient’s baseline in the THIRD TRIMESTER
What should you encourage before and after delivery?
Peeing
- Empties bladder before delivery (uterus and baby put pressure on bladder > full bladder can make it harder for baby to descend)
- Prevents bladder distention (uterus continues to contract and shrink post-delivery > can cause bladder to become compressed and distended if full)
Why is identifying the fundus important?
Allows us to estimate gestation based upon fundal height
What is most common in the first 6-14 weeks of pregnancy?
Nausea/vomiting (morning sickness)
- Can occur during the entirety of pregnancy or not at all
What is the medication commonly used for morning sickness classified as?
Antihistamines
- Crosses the blood brain barrier blocking H1 receptors (ex: Diclectin)
As blood volume and HR increase, how does this impact Cardiac Output?
It increases it
- Specifically by 30% in the THIRD TRIMESTER
What is Supine Hypotension Syndrome?
Compression of the inferior vena cava by the uterus
- Pregnant women >20 weeks have higher potential of this happening
- Compression of IVC causes decrease in preload
- Decrease in preload results in decreased cardiac output, which leads to hypotension and syncope
*Left lateral position limits compression and increases uterine blood flow. SUPER IMPORTANT IN CARDIAC ARREST
How much does Functional Residual Capacity (volume left after normal exhalation) decrease by during pregnancy?
25%
- Can cause increased RR
- Can also be from enlarged uterus placing pressure on diaphragm
- Fetus also requires more O2
What are considered Child Bearing Years?
14-50 years of age
What does Primip mean?
Short for PRIMIPARA
- Means that patient has only had one birth/delivery (past 20 weeks)
What does Multip mean?
Short for MULTIPARA
- Means that patient has had 2 or more deliveries (past 20 weeks)
What is considered a Geriatric Pregnancy?
If a woman is aged 35+
How many weeks/months is the FIRST TRIMESTER?
Week 1 - Week 12 (Approx. 3 months)
How many weeks/months is the SECOND TRIMESTER?
Week 13 - Week 27 (Approx 4 - 6 months)
How many weeks/months is the THIRD TRIMESTER?
Week 28 - Birth (usually around 40-42 weeks). Approx 7-9 months.
- These contractions last approx 30-60 seconds
- Benign and painless
- Do not progress in regularity or severity
- Body’s way of “training” for delivery
What is this called?
Braxton Hicks Contractions
- Can occur as early as the 2nd trimester
- Increase in frequency 2-3 weeks before onset of labour
- Uterus undergoes effacement (thinning of cervix) and dilation
During true/actual contractions, what will the abdomen feel like?
Rock hard
What are the Stages of Labour?
- Late Pregnancy/ Pre-Labour
- Stage One: Early Labour + Active Labour
- Stage Two: Passive + Active Phase
- Third Stage
What happens in Stage One: Early Labour + Active Labour?
- Begins with descent of infant - relieves pressure on upper abdomen but increases pressure in pelvis
- Contractions described as cramping, back pain, generalized abdo pain
- Mucus plug is expelled; “bloody show”
- Lasts 8-12 hours in first delivery, 6-8 or less thereafter
- 2 phases:
Latent (Dilation 3-4 cm)
Active (Dilation 5cm to 10cm)
What happens in Stage Two: Passive + Active Phase?
- FULL DILATION (10 cm): fetal head enters birth canal
- Urge to push or bear down is a HUGE indicator
- Heavy red show of blood
- Head (crowning) or other presenting part emerges
- Contractions are intense; 2-3 min intervals lasting 60-90 seconds
- Ends with delivery of infant
*500 mL of blood loss during labour
* Urination and BM may also occur during delivery
What is imminent birth described as according to the ALS?
Crowning or other presenting part is visible OR:
- In primips, presenting part is visible during and between contractions. Contractions <2 mins apart. Maternal urge to push + bear down
-In multips, contractions are 5 mins apart or less + any other sign of second stage labour present.
What happens in the Third Stage?
- Begins with delivery of infant and ends with placental delivery
- Placenta takes 30-60 mins to deliver
What are some good hx gathering and assessment questions?
- Do you know your due date?
- Last menstrual period?
- Are you receiving prenatal care?
- How far apart are your contractions? How frequent are they? How long do they last?
- Have you given birth before? Any complications or regular deliveries?
- Any past medical hx? (diabetics = huge babies)
What happens in NORMAL LABOUR?
1) Descent - Fetus moves down towards pelvis
2) Flexion - Fetal chin to chest
3) Internal Rotation - Fetal occiput turns towards maternal pelvis
4) Extension - Birth with head facing down
5) Restitution - Baby’s head rotates to side
6) Expulsion - Birth of baby
How do you deliver the placenta?
- Gush of blood (placenta will separate from uterine wall)
- May notice lengthening of cord or contractions afterwards
-Apply GENTLE controlled cord traction (CCT) & guard uterus with other hand (only after there is evidence of detachment)
- Encourage delivery and perform CCT if hemorrhage seems to be occuring
- Document time of delivery.
When the placenta is delivered, what should you do?
- Inspect it for wholeness
- Place in plastic bag from OBS kit: label with maternal patient’s name, time of delivery
- Delivery of placenta should not delay transport considerations/initiation
What is the importance of cranial sutures?
To allow for flexibility during birth
- Cranial sutures also allow for reshaping of the fetus’ head during delivery
- Complete fusion of cranial suture lines is ~18 months of age in child
What is Precipitous Labour?
Extreme rapid delivery:
- Delivery of baby within 3 hours of regular contractions
- More common with 2nd births “multips”
- Rapid labour may increase risk of perineal lacerations & postpartum hemorrhage due to uterine atony
What is uterine atony?
Medical condition: when uterus fails to contract properly after childbirth.
- Can lead to excessive bleeding and is a serious complication of childbirth.
- Most common cause of PPH (more than 500 ml of blood loss)
What are some things to be concerned about with Premature Births?
- Always at risk for hypothermia (true for all neonates)
- Usually requires resuscitation: poor lung compliance + no surfactant since alveoli are not fully formed
What are some malpresentations that will NOT deliver?
- Transverse lie
- Shoulder presentation
- Oblique lie
*In these scenarios, inspect perineum to rule out cord prolapse or limb presentation
What should you do with limb presentations?
- Do NOT push back in
- Discouraging patient from pushing - tell them to “pant” instead
- WRAP LIMB AND KEEP WARM
- Load and go babyyyy
Types of Breech Presentations?
- Frank Breech (most common): hips flexed and legs extended. Buttocks will present first
- Complete Breech: hips and knees are flexed. Buttocks and feet present together
- Footling Breech: One hip and knee flexes, other remains straight and enters birth canal first. Risk of cord prolapse is HIGH
*In all these scenarios, colour of amniotic fluid is important. Should be clear. If not, fetus may be in distress.
Should you attempt to deliver a baby if you see that they are in Frank Breech?
Yes
- Position patient, then tell them to push with contractions. HANDS OFF BREECH
- Once baby has been born to the umbilicus, you have 4 MINS TO DELIVER BABY COMPLETELY. Consider gentle release of legs if possible. HANDS OFF BREECH.
- Consider gentle release of arms at this point if possible. ALLOW GRAVITY TO BIRTH BABY. If hairline visible, do MSV
*Never touch cord in all circumstances
What is Placenta Previa?
When the placenta partially or completely covers the cervix
- Bleeding is bright red and PAINLESS
- Can occur when blastocyst implants too close to cervix
What is Placenta Abruptio?
Partial/full detachment of placenta at 20 weeks.
- Significant bleeding
- Severe abdominal pain; tearing pain
- Risk factors: trauma, previous c-section, pre-eclampsia/eclampsia, age of 35 years
- SECOND/THIRD TRIMESTER COMPLICATION
What is Placenta Accreta?
When the placenta grows too deeply into the wall of the uterus
When should you assume Pre-Eclampsia in patients?
- > 20 weeks gestation
- BP >140/90 (severe pre-eclampsia has a diastolic value of >110)
- Generalized edema
- c/o of headache, nausea, abdominal pain (with or without vomiting), blurred vision, fatigue, rapid weight gain
What is Pre-Eclampsia?
Pregnancy complication that typically develops after 20 weeks of gestation
- Characterized by high BP (>140/90)
- Proteinuria (protein in the urine)
- Proteins are big and shouldn’t be in urine. This is due to osmotic pressure
A pregnant woman is having a seizure. Immediately, what should the first thing be in your mind?
Eclampsia.
- Treat how you would normal seizures (maintain ABC’s: consider airway, O2)
- Only exception is to position left lateral
What is Gestational Diabetes?
Type of diabetes that develops during pregnancy.
- Typically develops in second or third trimester; goes away after baby is born
- Women who develop GD are at increased risk of developing Type 2 Diabetes later on in life
- BIG BABIES: be mindful of breech/shoulder dystocia with these patients
What is a Spontaneous Abortion (Miscarriage)?
Loss of pregnancy without outside intervention before 20 weeks gestation
- Often presents with light bleeding; possibly some clots
- Cramping and lasts for approx. 1 week
What is Gestational Trophoblastic Disease?
When abnormal cells or tumour develops in uterus from cells that would normally develop placenta
- Mostly benign but can be malignant
- Risk factors: maternal age <20 or >35, previous spontaneous abortion, molar pregnancy
What is Dysmenorrhea?
Pain during menstruation
- Very common
- Can be secondary to other factors such as endometriosis, pelvic infections, and fibroid tumours
What is Endometriosis?
When endometrium tissue grows abnormally
- Normally, endometrium (lining of the uterus) grows and sheds each month
- In endometriosis, tissue similar to lining of uterus grows on other areas such as ovaries, fallopian tubes, or other organs in pelvic area
S&S of Endometriosis?
- Dysmenorrhea
- Lower back and pelvic pain
- Pain during intercourse or after
- Painful bowel movements or pain when urinating
- Infertility
What is Disseminated Intravascular Coagulation (DIC)?
Serious medical condition that affects the body’s ability to control blood clotting
- Body normally forms blood clots to stop bleeding during injuries
- In DIC, body forms too many blood clots throughout the body
- These blood clots can block blood flow to important organs; leads to organ damage and failure
*Body depletes platelets and coagulation factors, leading to thrombolysis and massive bleeding
Stages of Shock?
Stage 1 (Compensated or Nonprogressive)
- Vasoconstriction, tachycardia, tachypnea occurs to retain fluid, along with renal
- This is due to blood shunting to core; pt may appear cyanosed with cool skin, poor cap refill
- Anaerobic metabolism begins, producing lactate and H+ ions (start of acidosis)
Stage 2 (Decompensated or pressive)
- Compensation is failing.
- Hypotension due to vasodilation, which decreases cardiac output.
- Possibility of decreased LOA here
Stage 3 (Irreversible)
- End of organ dysfunction and death
What is a thready pulse?
A pulse that’s longer instead of one quick beat. This is bad LOL.
What is a Uterine Rupture?
Spontaneous or traumatic rupture of uterine wall.
- Fetus can be expelled into peritoneal cavity.
- For this reason, limbs/head of fetus may be able to be palpated outside uterus
- May result from old scar openings (c-section) and trauma to uterus
- High fetal mortality: 50-75%
What are Ovarian Cysts?
Fluid filled sacs on ovaries
- As sacs grow and stretch, pain and discomfort results
- Eventually ruptures, which can cause serious hemorrhage
- C/O: unilateral lower abdominal pain, sudden and sharp
What is one of the most dangerous FIRST TRIMESTER complications, occurly most often at 6 weeks?
Ectopic Pregnancy
What is the clinical triad of ECTOPIC PREGNANCY?
- Pain
- Amenorrhea (lack of menstruation)
- Vaginal bleeding
