OB &GYN Flashcards
Changes in pregnancy:
- Reproductive system (4)
- Respiratory (5)
- Cardiovascular (4)
- GI (2)
- Urinary (4)
- musculoskeletal (2)
- Reproductive system (4)
- uterus b4 prego-2 oz holds 10ml; end of preg 2 lbs holds 5000ml
- preg vascular uterus 1/6 of total blood vol
- mucus plug opening of cervix
- breast enlarge nodular for lactation - Respiratory (5)
- O2 demand increase
- resp tract resistance decrease hormone smooth muscle dilation
- tidal vol increase 40%
- resp rate increase slightly
- increase O2 consumption, 20% - Cardiovascular (4)
- CO increase
- maternal blood volume increase 45%, incr RBC & plasma, but plasma greater=anemia
- HR incr by 10-15 bmp
- BP decr slight 1st 2nd trimester and then normal - GI (2)
- N/V 1st trimester need for carbs
- bloating constipation decr peristalsis - Urinary (4)
- renal blood flow incr
- GF incr 50% 2nd trimester
- bladder displaced superiorly anteriorly (incr risk injury)
- urine frequent - musculoskeletal (2)
- pelvic joints loosen due to hormone
- change in center of gravity
spontaneous abortion
- pathophysiology (3)
- assessment (3)
- pathophysiology
- 80% occurs prior to 12th weeks 1st tri
- 15-20% in preg genetics or uterine abnormality, infection, drugs, maternal dx
- cramping & vaginal bleeding 8-12 wks - assessment
- cramplike lower abd like labor or menstrual cramps
- moderate-severe vaginal bleeding
- passage of tissue or blood clots
Placenta previa
- pathophysiology (3)
1a. 3 types
1b. predisposing factors (6) - assessment (1)
- pathophysiology (3)
- major cause of 3rd tri bleeding
- abnormal implantation of placenta over or near opening of cervix (normal in fundus & posteriorly)
- bleeding not associated with abnormal uterine contraction or pain
- Total:completely covers os block birth canal and prevent delivery
- partial: may obstruct
- marginal: near neck of cervix
- predisposing factors: multiparity, rapid succession of preg, greater than 35, previa previa, hx vaginal bleeding, bleeding after intercourse - assessment (1)
- 3rd trimester bleeding painless
Abruptio Placentae
- pathophysiology (1)
1a. causes problems (
1b. types (2)
1c. predisposing factors (8) - assessment (7)
- pathophysiology (3)
- small arteries lining btw placenta and uterus prone to rupture–>accumulate blood tear & separate placenta from uterine wall
1a. causes (20: poor gas exchange, waste btw fetus & placenta; severe maternal blood loss
1b. types (2): complete and partial
1c. predisposing factors:
- HTn
- cocaine vasoactive drugs
- preeclampsia
- multiparity
- previous abruption
- short umbilical cord
- premature rupture of amniotic sac
- DM - assessment (7)
- vaginal blleeding constant abd pain (hallmark)
- abd pain due to muslce spasm
- pain lower back
- uterine contraction
- abdomen tender
- vaginal bleed varies in amount
- S&S hypovolemic shock present
Ruptured uterus
- pathophysiology
- Assessment
- pathophysiology
- uterine enlarge in preg and thin around cervix
- lead to rupture wall and release fetus into abd cavity
- 5-20% maternal mortality and >50% infant mortality
- rupture requires immediate surgery - Assessment
- hx previous rupture
- hx abdominal trauma
- hx large fetus
- multiparity
- hx prolonged & difficult labor
- hx C-sec or uterine surgery
- tearing or shearing sensation in abdomen
- constant & severe abd pain
- nausea
- S&S shock (hypoperfusion)
- vaginal bleeding
- cessation of uterine contraction
- palpatable infant in abd cavity
Description of perineal injuries:
- vascularity
- causes
- management
- very vascular, large blood loss, painful
- sexual assault,
- straddle injury from bicycle
- gymnastics
- lacerations or hematomas
- urethral injuries - control bleeding with direct pressure
- apply ice pack
- menstrual cycle how often?
- what happens?
- where is the fertilization occurs and after how many days?
- no fertilization?
- every 28 days egg released
- blood supply to uterus increases, wall thickens
- implant in uterus wall after 7 days
- egg, extra blood, tissue discarded=period
Understand anatomic and physiologic
changes of pregnancy
Changes:
Identify 5 pre-delivery emergencies
- Bleeding in early pregnancy
- Threatened abortion/still birth
- Pre-eclampsia and eclampsia
- Trauma in pregnancy
- Ruptured uterus
what is a placenta?
- Vascular organ
- Exchange area for nutrients, O2
- Expelled after birth
Umbilical Cord
• 2 way blood flow
• 3 vessels surrounded by clear
protective (1 veins, 2 arteries)
Amniotic sac
- Grows from placenta
- Encases fetus
- 16-32 ounces of clear watery liquid
5 Pregnancy changes in Cardiovascular
-three result of hypovolemia
- plasma volume up 50%
- RBC up 18-30%
- pulse up 15-20 bpm
- BP lower than normal
- Hypovolemia
- response is constriction of uterine arteries
- redirect flow to major organs
- can be intensified with position of patient
Supine hypotensive syndrome of pregnancy (3)
• Fetus presses on inferior vena cava • Inhibits venous return to the heart • Decreases cardiac output
4 changes in Pregnancy - Pulmonary
§ Respiratory rate – same or slightly increased § Tidal volume up 50% § O2 demand increased § Progesterone relaxes muscle • feeling of air hunger
3 changes in preganncy-GI
-what effects does progesterone have on GI (3)
§ Uterus physically crowds abdominal contents
§ Assume stomach is full
§ Aspiration is possible
progesterone has a slowing effect on GI tract
- decreased rate of gastric emptying
- food remains in stomach for longer time
- relaxation of sphincter btw stomach and esophagus
2 changes in pregnancy-uterus
-2 effects of increased blood flow to uterus?
§ Uterus is more susceptible to injury as it
leaves the bony pelvis and acts as barrier for
other organs
§ Blood flow to uterus is enhanced
• Increased vascularity is serious if uterus is injured
• Pelvic fractures cause severe blood loss
- location of ectopic pregnancy
- time frame
- mistaken for
- 9 description of Ectopic pregn
§ Ectopic pregnancy • 90% occur in fallopian tubes § 4 to 6 weeks pregnant § Often mistaken for appendicitis
- History of amenorrhea
- Positive pregnancy test result
- Abdomen swollen
- Patient may not tell/ know she is pregnant
- Bleeding usually light
- Poorly localized lower abdominal pain
- Pain may radiate to shoulder area and may
be severe - Some vaginal or rectal pain may be present
- Nausea and vomiting
management of Ectopic pregnancy
- if pt lost much blood->tx for shock if hypovolemia symptoms are present
- life threatening
Placentia Previa (3)
§ Placentia Previa • Occurs when placenta implants over cervix • Painless bleeding in late pregnancy • No way to diagnose prehospital
Placental Abruption
Placental Abruption
• Premature separation of placenta from uterus after 20 weeks gestation
• Sudden onset intense abdominal pain
Risk factors of placental abruption
- is bleeding present?
- what needs to be monitor
- Hypertension
- Preeclampsia
- Cocaine use
- Trauma – direct blow or accel/decel force
-Vaginal bleeding not
always present
- Need fetal monitoring
Treatment of Placental Abruption
§ Treatment
• Focus is on prevention and treatment of shock
• Place patient on her left side
• Elevate hips with pillows to alleviate pressure on the cervix
• Administer O2
• Monitor vital signs
- Abortion before 30 wks, after 20wks
- early premie viability
- signs of abortion/miscarriage
§ Abortion/miscarriage
• Loss of pregnancy before 20 wks gestation
• Stillbirth - after 20 wks
• Earliest age of viability that an infant can survive
outside the womb is approximately 23 wks
§ Signs
• Loss of substantial amount of blood
• Leaking of amniotic fluid in the 1st trimester
what is the second leading cause of maternal death?
-list 6 symptoms of it
Pre-eclampsia/eclampsia
-2nd leading cause of maternal death in US
-Symptoms include:
• BP > 160-180
• Decreased urine
• Visual changes
• Pulmonary edema
• Seizures
• Bleeding disorders
tx for pre/eclampsia
§ Treatment
• Provide quiet, dark environment
• Use soft voice; avoid jostling or noise
• Have suction available in case a seizure begins
• If seizures occur, administer O2
• Transport in left lateral recumbent position
-can occur after 20 days postpartum
first leading cause of maternal death
- what can prevent/reduce severity?
- increase pressure from lap belt cause (3)
§ MVCs are responsible for majority of all
injuries
• Injury is less severe if mother is wearing a seat
belt with shoulder restraint
• Sudden increase in pressure from lap belt alone
can cause:
• Burst-balloon uterine rupture
• Abruptio placentae
• Fetal death
- premature labor by blunt trauma cause (3)
- fetal outcome determined from trauma?
- what causes uterine lacerations?
- uterine stimulation by blunt trauma:
-Precipitate labor contractions
• Cause premature membrane rupture
• Abruptio placentae - Fetal outcome determined by:
• Extent of placental abruption
• Rapidity of treatment
• Fetus age
3.broken ribs or pelvic bones
Treating pregnant trauma victim
Treating pregnant trauma victim • Recall physiologic changes of pregnancy • Assume stomach is full • Treating 2 patients • Prevent shock • Spinal precautions • Initial ABCs • Pregnant transport position
§ Patients beyond the 20th week
should be tilted 15° to the left
§ Place rolled towels beneath the
spinal board
§ Can get supine hypotension
syndrome when uterus compresses inferior vena cava
§ Can decrease cardiac output by up to 30%
So what happens if your pregnant patient
codes?
§ ABC’s § Adequate chest compressions with patient tilted to the left § ACLS protocols § Transport to nearest facility ASAP
Symptoms (3) of uterine rupture
-9 risk factors
§ Symptoms
• Pain
• Bleeding with shock
• Cessation of contractions
§ Risk Factors • Prior cesarean section • Prior rupture • Trauma • Injury from instrumentation • Uterine anomalies • Malpresentation • Fetal anomaly • Obstructed labor • Excessive uterine stimulation due to crack-cocaine
1st stage o labor
-contraction is timed?
1st stage • First contraction to full cervical dilation • Intermittant contractions • NOT Braxton Hicks § Contractions • Timed from beginning of 1 to beginning of next • Become more painful, longer & closer together • Bloody show may be seen • Amniotic sac may break any time
2nd stage of labor
§ 2nd stage • “Pushing stage” • Begins when cervix dilated • Ends with birth • Usually 1+ hours with 1st baby • Pressure on the rectum by fetal head as it descends causes urge to push
3rd stage of labor
§ 3rd stage • Begins with delivery of baby • Ends with placenta delivery • Uterus greatly reduced in size • Uterine wall reduced • Placenta is squeezed off uterine wall • Uterus contracts into hard ball & slows flow of blood from open blood vessels
visual examination
• Check for distention or bulging of the perineum
• Inside wall of the rectum may be visible as
sphincter is stretched open
• Perform during contraction
• Crowning
• Presenting part descends into pelvis
• As presenting part fills the pelvic cavity, any fecal
material in the mother’s rectum is expelled
6 cardinal movement of labor
- engagment
- flexion
- descent
- internal rotation
- extension
- complete extension
- external rotation/restitution
- delivery of anterior shoulder
- delivery of posterior shoulder
management of shoulder dystocia
HEL(egs)P(ressure)E(nter vagina)R(oll)
- episiotomy
- maternal hips are flexed knees on abdomen
- causing rotation of maternal pelvis and increasing size of pelvic outlet
- suprapubic–pressure applied to drive fetal shoulder downward under pubic bone
- insert hand to level fetal elbow, grasp forearm, sweep across chest to deliver posterior arm/shoulder
- roll anterior shoulder toward fetal chest and add posterior shoulder pressure toward chest
If unable to deliver shoulder dystocia after manual manupulation
- fracture fetal clavicle
- symphysiotomy (divide cartilage of pubic symphysis)
- cesarean section
Cord prolapse
- rare in term cephalic pregnancies (0.4%)
- more common in malpresentations
1. footling breech (15-18%)
2. transverse lie (up to 20%) - dx by palpation of cord on exam
managment of cord prolapse
- manual replacement
- mom onO2
- trendelenberg and or left lateral decubitus
- push presenting part off cord
- immediate C-section
postpartum hemorrhage
§ Blood loss greater than 500 mL after delivery § Early – 1st 24 hrs • Genital lacerations • Uterine rupture • Coagulation defects § Uterine inversion • Excessive traction on cord • Bearing down too hard during 2nd stage of labor § Uterine prolapse • Supporting structures fail • Uterus falls out of vagina
uterine atony
§ Uterine atony • Uterus fails to contract • Massive bleeding from the vagina • Signs of shock quickly follow • Uterus poorly defined, soft, boggy mass • Often above the level of the umbilicus • Uterus should be massaged until it is firm and hard • If bleeding is severe, treat for shock
Late postpartum hemorrhage
§ Late postpartum hemorrhage • 6 to 10 days later • Retained placental tissue • Infection • Coital (sexual) trauma • Rupture of episiotomy wound
§ May be able to control bleeding: • Uterine massage • Direct pressure with sanitary pad • Do not place packing or dressings inside the vagina
