COMPLICATIONS of PREGNANCY and DELIVERY Flashcards
Week 2
What are 7 risk factors that affect pregnancy?
- Being older than 35
- Being younger than 20
- Smoking cigarettes/drinking alcohol
- Being pregnant with twin, triplets, or more
- Having a hx. of miscarriage
- Having obesity
- Having anorexia
What are some things that you would do/assess to determine a problem in an OB patient?
- Assess the abdomen
- Vital signs
- Contractions
- Fluid colors
- Listen when the patient says “something feels wrong”
- Watch for potential seizures
What are 7 health conditions that can complicate pregnancy?
- Diabetes
- Cancer
- High blood pressure (HTN)
- Sexually transmitted infections (STIs)
- Kidney problems
- Epilepsy
- Anemia
What are the 3 main 1st trimester complications?
- Ectopic pregnancy
- Miscarriage
- Hyperemesis
What is an Ectopic Pregnancy?
A condition where the fertilized egg implants outside your uterus (usually in your fallopian tube 90% of the time)
When is an Ectopic Pregnancy usually diagnosed? When does it most often occur?
An ectopic pregnancy is diagnosed before 12 weeks and it occurs most often around 6 weeks
What are 5 causes of an Ectopic Pregnancy?
- Pelvic Inflammatory Disease
- Intrauterine device
- Previous ectopic pregnancy
- Advanced maternal age
- Tobacco use
Regarding and Ectopic Pregnancy, what is the “Classic Clinical Triad” of symptom presentation?
- Pain
- Amenorrhea
- Vaginal Bleeding
When ruptured, an Ectopic Pregnancy patient will present with hypotension and shock…What affect does this potentially have on the Cardiac System?
Bradycardia or a lack of Tachycardia in the hypovolemic patient
What is a Miscarriage (Spontaneous Abortion)?
A loss of pregnancy that occurs naturally before 20 weeks
What is the most common cause of a Miscarriage (Spontaneous Abortion)? How common are they?
- Chromosomal problems/abnormalities
- They are common in about 1 in 4 pregnancies
How does a patient experiencing a Miscarriage (Spontaneous Abortion) usually present?
- Potentially shows signs of hypovolemic shock (low blood pressure, pale, bradycardia…etc..)
- Vaginal bleeding (light or with clots, tissue, and/or cramping that occurs for approx. 1 week)
- Massive bleeding with hypovolemia
What is Hyperemesis Gravidarum?
It is a condition where a pregnant patient experiences severe nausea and vomiting
What are 4 things that Hyperemesis Gravidarum can cause?
- Dehydration
- Vertigo
- Weight loss
- Preterm labor
What causes Hyperemesis Gravidarum?
High levels of human chorionic gonadotropin (HCG)
What are five 2cd and 3rd trimester complications?
- Pre-eclampsia
- Eclampsia
- Gestational Diabetes
- Placenta Previa
- Abruptio Placenta
What is Pre-eclampsia? When does it occur?
A hypertensive disorder, characterized by HBP & signs of damage to another organ system (kidney/liver) that occurs after 20 weeks but, it can also develop up to 10 weeks after delivery
What are some signs and symptoms of Pre-eclampsia?
- BP > 140/90
- Severe headache
- Blurred vision
- Upper abdominal pain
- Nausea/vomiting
- Edema
- SOB
- Decreased urine output
What are 6 risk factors for Pre-eclampsia?
- Hx. of Pre-eclampsia in a previous pregnancy or family hx.
- First pregnancy (primigravida)
- Significant health hx. before pregnancy (diabetes, lupus, HBP, kidney disease, etc..)
- Obese (BMI > 30)
- Having more than 1 baby (twins, triplets, etc..)
- Age (young < 18 or advanced > 35)
What is Eclampsia?
It is the onset of seizures in a pregnant patient with Pre-eclampsia; when a pregnant patient suffering from HBP experiences 1 or more convulsions
What are 4 signs and symptoms of Eclampsia?
- SEIZURES!!!
- HBP
- CONVULSIONS!!!
- Blurred vision
How would you treat a patient with Eclampsia?
- Recognize the signs/symptoms
- Treat the underlying symptoms
- Provide supportive care
What is Gestational Diabetes?
It is diabetes that is caused by pregnancy due to carbohydrate metabolism
When a pregnant person has Gestational Diabetes, how does it affect the production and use of insulin?
It causes the pregnant patient to not be able to produce and use all the insulin that is needed
Why is it that pregnant patients that have Gestational Diabetes commonly give birth to “larger” babies?
Because the excess glucose form the lack of insulin production/usage is transferred to the fetus and stored as fat
What are some signs and symptoms of Gestational Diabetes?
- Increased thirst
- Frequent urination
- Nausea
- Fatigue
- Frequent bladder and skin infections
- Yeast infections
- Blurred vision
- Dry mouth
What is Placenta Previa?
It is when the placenta partially or fully covers the cervix
When does Placenta Previa occur?
It can occur when blastocyst implants too close to the cervix
What color is bleeding with Placenta Previa?
Painless, bright red bleeding
What are 9 Risk Factors for Placenta Previa?
- Previously had a baby
- Had a previous C-Section Delivery
- Scars on uterus from a previous surgery or procedure
- Had placenta previa with previous pregnancy
- IVF treatment
- Carrying more than one fetus
- Age 35 or older
- Smoke cigarettes
- Use cocaine
What are some signs and symptoms of Placenta Previa?
It is typically asymptomatic but can often produce bright red bleeding
What is Abruptio Placenta?
Partial/full detachment of the placenta at 20 weeks
When does Abruptio Placenta occur?
When vascular structures are torn away from the uterine lining
What does a patient experiencing Abruptio Placenta usually complain of?
Severe, sometimes tearing, abdominal pain …. bleeding can sometimes be a complaint but not always
What are 6 risk factors for Abruptio Placenta/
- Trauma
- Multiple fetuses
- Short umbilical cord
- Previous c-section(s)
- Pre-eclampsia/eclampsia
- Age of 35 years or older
What are 3 signs/symptoms of Abruptio Placenta?
- +/- Vaginal bleeding
- Contractions do not relax
- Abdominal pain
How do you as a Paramedic treat Abruptio Placenta?
You treat the underling symptoms and rapidly transport the patient
What is an Amniotic Fluid Embolism?
It is when amniotic fluid, fetal cells, hair, or other debris enters into the maternal pulmonary circulation, causing cardiovascular collapse
True or False: an Amniotic Fluid Embolism is uncommon and catastrophic and typically occurs in labor or 30 minutes after delivery
True
How can a patient experiencing an Amniotic Fluid Embolism present (Signs and Symptoms)?
Much like a massive PE with dyspnea
1. Increased WOB
2. Hypoxia
3. Hypotension
4. Possibly cardiac arrest (PEA rhythm)
5. Chills/vomiting
6. Sudden SOB
What are 10 risk factors for an Amniotic Fluid Embolism?
- Older than 35 years of age
- Experiencing a multiple fetus pregnancy
- Fetal distress
- Issues with the placenta (like placental abruption)
- Pre-eclampsia/eclampsia
- Polyhydramnios
- Labor induction, medications or procedures
- Having a c-section delivery
- Cervical tears
- Operative assisted deliveries (forceps delivery, vacuum extraction)
What is Vertex Presentation?
It is when the fetus is facing head down (face to butt)
With regards to the delivery of twins, post-partum hemorrhage is a possibility. This can cause overdistention of the uterus and may result in uterine atony. What medication can you as a Paramedic give to help with this complication?
Oxytocin
When you are delivering twins, what is the appropriate time to clamp the cord?
After the delivery of the 1st twin
What are the 2 types of twins?
- Fraternal (dizygotic) twins
- Identical (monozygotic) twins
What are 3 complications of being pregnant with twins?
- Smaller than anticipated birth weight
- Fundal height remains high
- Fetal parts may be able to be palpated through the abdomen
What is considered a Premature Birth?
A birth that is pre-37 weeks gestation
Why does a pre-mature birth baby usually have poor lung compliance (hard to squeeze BVM)?
Because their lungs lack surfactant (alveoli are not fully formed)
What can you as a Paramedic do when a baby is presenting with Nuchal Cord?
Remove the cord
1. Slip over the head or body
2. Clamp/cut the cord if unable to slip over the head or body
What is Nuchal Cord?
When the umbilical cord is wrapped around the neck
What is Precipitous Labor?
It is when the delivery of the baby is within 3 hours of regular contractions (extremely rapid delivery)
How can you help manage a Precipitous Labor?
The same as any delivery
1. Encourage panting vs. pushing
2. Place mom in a position where gravity isn’t working against you
3. Guard perineum
4. Control delivery of the head
5. Reassure mom
What are 8 Birthing Malpresentations?
- Occiput Anterior (Face down-Vertex presentation)
- Occiput Posterior
- Breech
- Transverse Lie
- Face
- Compound
- Brow
- Limb Presentation
What is the Occiput Posterior presentation?
When the fetal occiput is posterior in relation to the maternal pelvis (“Sunny side up”)
What can be discovered upon abdominal examination of a patient experiencing Occiput Posterior fetal presentation?
The lower part of the the abdomen is flattened, feta limbs are palpable anteriorly and fetal heart may be heard in the flank
What can be discovered upon vaginal examination of a patient experiencing Occiput Posterior fetal presentation?
The posterior fontanelle is towards the sacrum and the anterior fontanelle may be easily felt if the head is deflexed
What is the Transverse Lie malpresentation?
When the head and breech can be felt with exam of the abdomen
What is the Shoulder Presentation malpresentation?
When the shoulder presentation is the presenting part
What is the Oblique Lie malpresentation?
When the fetus lies on a diagonal angle
What is the Limb Presentation malpresentation?
When the fetus presents with either a leg or an protruding from the vagina
Can you as a Paramedic deliver a fetus that is experiencing limb presentation?
Yes however, it depends on what limb is presenting. If an arm is presenting you CANNOT deliver the fetus…if a leg is presenting, it IS possible to deliver the fetus
What are 3 things you as a Paramedic should do when a patient is experiencing limb presentation of a fetus?
- DO NOT push the baby back in
- Discourage the patient from “pushing”, tell the patient to “pant”
- If unable to deliver the fetus you wrap the presenting limb and keep it warm
What causes Brow Presentation of a fetus?
Partial extension of the fetal head so that the occiput is higher than the sinciput (front of skull, forehead to crown)
What can be discovered upon abdominal examination of a patient experiencing Brow Presentation?
More than half the fetal head is above the symphysis pubis and the occiput is palpable at a higher level than the sinciput
What can be discovered upon vaginal examination of a patient experiencing Brow Presentation?
The anterior fontanelle and the orbits are felt
What are the 3 different types of Breech presentation?
- Frank Breech (most common)
- Complete Breech (full)
- Footling Breech (Foot 1st - will not deliver of knees locked on pelvic girdle)
How does Footling Breech present?
Hips flexed and legs extended over the anterior surface of the body, buttocks will be viewed from the cervix
How does Complete Breech present?
Both hips and knees are flexed, therefore buttocks and feet enter cervix first
What are 5 things you can do to support a patient experiencing a Footling Breech presentation delivery?
- Place patient into a gravity position (side of bed, upright, or supported squat position)
- Encourage voiding (may increase internal space for fetal descent)
- Get an assistant to apply gentle fundal pressure to keep the fetal head flexed
- Encourage the patient to push when the presenting part is visible (“hands off” until then)
- DO NOT pull is the fetus is progressing naturally
How does Footling Breech present?
One hip and knees flexed, while other remains straight and enters the birth canal first. Buttocks and legs do not provide an adequate wedge to open the birth canal.
What is a gentle maneuver to assist with a Breech Delivery? How do you perform this maneuver?
Insert your finger behind the knee “popliteal fossa”
1. Flex knee
2. Abduct thigh
3. Legs will deliver spontaneously
4. DON’T touch the cord unless ABSOLUTELY necessary
What is the 1st step of the Mauriceau-Smellie-Veit maneuver?
- Lay the neonate along one forearm with the palm supporting the neonate’s chest and the 2 fingers exerting gentle pressure on the neonate’s face to increase flexion
What is the 2cd step of the Mauriceau-Smellie-Veit maneuver?
- Place the other hand on the neonate’s back with 2 fingers hooked over the shoulders and the middle finger pushing up on the occiput to aid flexion
What is the 3rd step of the Mauriceau-Smellie-Veit maneuver?
- When the hairline becomes visible, lift the body in an arc to assist the fetal head in pivoting around the symphysis pubis and allow the face to be born slowly. If a 2cd Paramedic is available, have him/her apply suprapubic pressure
What is the 4th step of the Mauriceau-Smellie-Veit maneuver?
- Lift fetal body in an “arc” to assist head delivery “bum to mom”
What is Cord Prolapse?
When the umbilical cord precedes neonate through the cervix (cord presets 1st), the umbilical cord is compressed by the following neonate
What can Cord Prolapse lead to?
Fetal hypoxia or death, secondary to cord compression
How can Paramedics manage Cord Prolapse?
- Explain the situation to the mother; need for a c-section
- Assist pt. into “knee-chest” position
- Apply sterile gloves
- Gently assess the cord for pulse
When managing Cord Prolapse, what should you do when you notice a week pulse in the cord?
- Tell the mom what you are doing…gently cradle the cord in your hand
- replace the cord into the vagina while inserting fingers into the vagina & apply manual digital pressure on presenting part
- Lift the presenting fetal part off of the cord to relieve compression
- If correctly elevating presenting part, the cord pulse should become stronger
- Keep your hand in position for the ENTIRE transport
What should you do when managing Cord prolapse and the cord has a strong pulse?
Replace cord into the vagina ( utilize minimum cord handling to reduce “vasospasm”) … if not possible, cover it with a moist, sterile dressing
Can you deliver a fetus experiencing Cord Prolapse?
Yes however, ONLY if delivery is absolutely IMMINENT
How should you position a patient on a stretcher who is experiencing cord prolapse?
In the Exaggerated “Sims” position, elevate hips to use gravity to help hold the cord in
What is Shoulder Dystocia?
Impaction of anterior shoulder against the symphysis pubis after delivery of the fetal head or posterior shoulder impacted against sacral promontory
When does Shoulder Dystocia occur?
When fetal shoulder are unable to birth either spontaneously or with gentle flexion of the head
What is the commonly known sign that you will see with a patient experiencing a Shoulder Dystocia delivery?
Turtle Sign (head advances and then retracts with contractions)
In regards to Shoulder Dystocia…..True or False: Critical, irreversible hypoxic injury will occur at the 8-minute mark once the head is born?
True
What are 7 risk factors for Shoulder Dystocia/Impacted Shoulder?
- Prior shoulder dystocia
- Gestational diabetes
- Postdate deliveries
- Maternal short stature
- High pregnancy weight and weight gain
- Abnormal pelvic anatomy
- Previous instrumented delivery
In regards to Shoulder Dystocia, how long do you have to deliver the body of a fetus once the head has been delivered?
4 minutes
What is the acronym that describes the steps you follow regarding a Shoulder Dystocia delivery?
- A: ask for help (you will require 2+ people)
- L: lift legs, hyperflex thighs (McRobert’s Maneuver)
- A: adduct shoulder (apply suprapubic pressure)
- R: rollover (Gaskin’s Maneuver)
- M: manually delivery of posterior arm (if visible at the perineum)
What are 4 Maternal complications with Shoulder Dystocia?
- Soft tissue injuries
- Anal sphincter damage, cervical or vaginal tears, etc..
- Uterine rupture
- Postpartum hemorrhage
What are 6 Neonatal complications with Shoulder Dystocia?
- Clavicle fracture
- Fetal acidosis
- Humeral fracture
- Brachial Plexus Palsy (transient/permanent)
- Hypoxic brain injury
- Death
How do you apply suprapubic pressure?
Done in conjunction with the McRoberts’s Maneuver - use your palm or fist to press down on your abdomen, just above the pubic bone
What is the McRoberts’s Maneuver?
When you place the patient’s knees to their chest and then tell the patient to stop pushing
Other than the Gaskin’s Maneuver, what else to you do during the R phase of ALARM?
- Apply gentle, downwards traction to the fetal shoulder against the maternal sacrum
- Apply gentle upwards traction to the fetal shoulder away from the maternal sacrum
In regards to the R phase of ALARM, how do you manually deliver the posterior arm?
Insert a hand into the vagina behind the posterior fetal shoulder to grasp the fetal elbow and bend it to the fetal chest. Then, with gentle traction, the fetal elbow is delivered…followed by the delivery of the posterior shoulder
If ineffective, how many time can you attempt each step of ALARM before you switch with your partner? How many total times before you transport the patient?
You can attempt ALARM 1 time before you switch with your partner…ALARM can be completed 2 times before you transport your patient
When can Post Partum Hemorrhage occur?
Right after delivery or up to 12 weeks after
What are the 4 main causes of Post Partum Hemorrhage?
- Tone: exhausted uterus & cannot contract
- Tissue: parts of placenta still retained & clotting compromised
- Trauma: uterine rupture/lac during delivery
- Thrombin: coagulation abnormalities
Hemorrhage is defined as _____ml or more severe Post Partum Hemorrhage is at 1 L
500 ml
True or False: blood estimation can be a poor indicator, so treat any patient presenting with hypovolemic shock as Post Partum Hemorrhage
True
When should an External Uterine Massage not be performed?
If the Placenta has not been delivered
What do you do if bleeding continues after attempting a Uterine Massage?
Perform External Bimanual Compressions`
What is the External Uterine Massage that should be performed in an attempt to stop Post Partum Hemorrhage?
A fundal massage
How do you perform a Fundal Massage?
- Explain to the patient that it may be uncomfortable but it is necessary
- Place 1 hand on the lower abdomen and use smooth, circular movement to massage the uterus
- If working, reassess frequently (10-15 minutes)
- Have mom attempt to empty their bladder
In what 2 situations can External Bimanual Compressions be performed?
- The placenta has been delivered and a fundal massage fails
- The placenta has not delivered and Post Partum hemorrhage is present
How do you perform External Bimanual Compressions?
- Place 1 hand above symphysis pubis & another hand on top of the fundus
- Squeeze both hands together for 5-10 minutes, until bleeding stops…keep hands in this position for the ENTIRE transport duration
What drug can be given post-delivery and/or after delivery of the placenta to limit or control PPH?
Oxytocin
What is Oxytocin? What does it do?
Oxytocin is a chemically synthesized hormone that stimulates uterine contraction and increases tone
How can you encourage natural Oxytocin production, and uterine contractions, within the maternal patient?
Encourage the mother to breastfeed or stimulate their nipples
How do you as a Paramedic administer Oxytocin?
It is administered IM
What is Meconium?
Meconium is a newborn’s 1st stool/bowel movement
What do you as a Paramedic do when Meconium is present?
- Use bulb suction if required, wipe mouth and nose with gauze if required
- provide respiratory support is required
- Provide routine/supportive care
- report the color to receiving staff
What are the most common traumas seen with pregnancies?
- MVC’s
- Assaults
- Falls
What statistic should be a part of your discussion with pregnant patients who are refusing transport due to a “minor injury”?
60-70% of fetal loss is reported from minor injury
Regarding trauma in pregnancy… prehospital treatment should be maximized for _______ survival
maternal (because mortality of the fetus relies on the mother)
Regarding trauma in pregnancy… in cardiac arrest with a futile prognosis, and ongoing CPR, where should you consider transporting the patient to?
A hospital capable of emergency c-section
What are the 3 types of shock that can be seen in pregnant patients?
- Compensated shock
- Decompensated shock
- Irreversible shock
What is compensated shock?
When the body experiences a state of low blood volume but is still able to maintain normal blood pressure and organ perfusion by increasing HR and constricting the blood vessels
What is decompensated shock?
The late phase of shock where the body’s compensatory mechanisms (increased HR, vasocontraction, increased RR) are unable to maintain adequate perfusion to the brain and organs
What is irreversible shock?
It is the form of shock that is not correctible, multiple end-stage organ failure and death occurs
