Obstetrics

Question 1

anatomy and physiology of the female reproductive

Answer 1

• cervix
• sacrum
• rectum
• vagina
• placenta
• uterus
• amniotic fluid
• bladder
• pubic symphysis

Question 2

placenta

Answer 2

• attaches to the inner lining of the wall of the uterus and connects to the fetus by the umbilical cord
• the placental barrier consists of two layers of cells
• after delivery, the placenta, or afterbirth separate from the uterus and delivers
• very vascular
• connects fetus and mother
• umbilical vein carries oxygenated blood*
• umbilical artery carries deoxygenated blood from baby to mom*

Question 3

umbilical cord

Answer 3

• lifeline of the fetus
• the umbilical vein carries oxygenated blood from the women to the fetus**
• there is one umbilical vein**
• the umbilical arteries carry deoxygenated blood from the fetus to the woman**
• there are two umbilical arteries **

Question 4

amniotic sac

Answer 4

• the fetus develops inside a fluid filled baglike membrane called the amniotic sac, or bag of waters
• contains about 500-1,000mL (ccs) of amniotic fluid
• fluid helps insulate and protect the fetus in development
• fluid increases as you get further along
• routinely check amniotic fluid levels
• fluid is released in a gush (sometimes) when the sac ruptures, usually at the beginning of labor
• you can break the water manually
• you can remove the baby with the sac present if premature

Question 5

stages of labor

Answer 5

• dilation of the cervix
• delivery of the infant
• delivery of the placenta

Question 6

first stage

Answer 6

• begins with the onset of contractions as the fetus enters the birth canal
• Braxton hicks- contractions prior to delivery (not always present)
• longer, more frequent, more painful, more regular, and short time in-between contractions before ***
• 0-1 cm dilation initially
• full cervical dilation is 10 cm dilated
• usually the longest stage, lasting an average of 16 hours
• quicker in lower weight children or previous pregnancy
• uterine contractions become more regular and last about 30-60 seconds each (60 seconds is usually peak)
• some women experience a premature rupture of the amniotic sac -> fetus not ready to be born -> provide supportive care and transport
• PROM- premature rupture of membrane
• toco monitor- assess baby heart beat
• ultrasound to check positioning
• head of the fetus descends into the women’s pelvic as it positions for delivery -> this is called lightening

Question 7

lightening

Answer 7

• head of the fetus descends into the womans pelvis as it positions for delivery
• this never occurs in some women -> then c-section
• usually give 2 hours of attempting to push to then decide for c-section (longer for women with epidural)

Question 8

second stage

Answer 8

• begins when the fetus begins to encounter the birth canal past the cervix
• ends when the infant is born (spontaneous birth) by vaginal delivery (or c-section)
• uterine contractions are usually closer together and last longer
• never let the mother sit on the toilet -> catheterized
• the perineum will bulge significantly (gets larger), and the top of the infants head will appear at the vaginal opening (or limb/butt -> breached) -> this is crowning

Question 9

crowning

Answer 9

• perineum will bulge significantly, and the top of the infants head will appear at the vaginal opening
• head only
• not limbs or butt

Question 10

third stage

Answer 10

• begins with the birth of the infant and ends with the delivery of the placenta
• the placenta must completely separate from the uterine wall -> not done forcefully, its done naturally (can cause hemorrhage)
• always follow standard precautions to protect yourself, the infant, and the mother from exposure to body fluids

Question 11

hypertensive disorders: preeclampsia (HDP)

Answer 11

• preeclampsia is a common complication
• pregnancy induced hypertension
• protein in the urine
• visual disturbances -> photophobia
• swelling in hands, feet, umbilical cavity
• 140/80/90 -> at risk for preeclampsia
• can continue for at least two weeks post-partum
• can develop after the 30th week of gestation (some as early as 20)
• signs and symptoms include headache, seeing of spots, swelling in the hands and feet, anxiety, and high blood pressure
• not sure what causes it but some women are more predisposed

Question 12

hypertensive disorders: eclampsia

Answer 12

• characterized by seizures that occur as a result of hypertension
• when does preeclampsia become eclampsia -> seizure*
• assume its a eclamptic seizure before anything else
• life threatening
• to treat:
• lie the patient on her side, preferably the left
• maintain an airway
• provide supplemental oxygen
• if vomiting occurs, suction the airway
• provide rapid transport and call for ALS
• IV magnesium in very high doses (4-6G) **- to stop seizures

Question 13

bleeding: ectopic pregnancy

Answer 13

internal bleeding may be the sign of an ectopic pregnancy

• a pregnancy that develops outside the uterus, most often in the fallopian tubes
• occurs about once in every 300 pregnancies

Question 14

bleeding

Answer 14

• the leading cause of maternal death in the first trimester is internal hemorrhage following rupture of an ectopic pregnancy
• hemorrhage from the vagina that occurs before labor begins may be very serious
• painless bleeding is most commonly caused by placenta previa - part of or all of placenta attaches on uterine wall and around cervix and vaginal opening -> as long as its not a lot and they arnt anemic its ok

Question 15

uterus

Answer 15

where baby develops

Question 16

amniotic fluid

Answer 16

surrounds amniotic sac

• amniotic fluid is fetal urine
• premature rupture of membranes - early breaking of water PROM
• you do not need amniotic fluid

Question 17

PDA (Patent Ductus Arteriosus?) and PFO (patent foramen ovale)

Answer 17

• fetal circulation
• dont need lungs to breath
• bypasses pulmonary circulation
• lungs are one of the last things to develop
• PDA and PFO exist in fetal circulation and then close

Question 18

30-34 weeks

Answer 18

lungs develop

-premature babies need support with breathing

Question 19

50%

Answer 19

• is are c sections
• we want to get it down to 30%
• higher potential for side effects
• longer hospital stay
• more expensive
• blood transfusion or support
• respiratory conditions are associated with c section (asthma, seasonal allergies)

Question 20

ectopic pregnancy

Answer 20

• development of zygote anywhere other than uterus
• most frequently the fallopian tube
• abdominal pain
• ruptured ectopic pregnancy is a surgical emergency
• you can bleed to death
• any abdominal pain from a female in child bearing age that is sexually active is an ectopic pregnancy until proven otherwise

Question 21

spontaneous abortion/miscarriage

Answer 21

• in abruptio placenta, the placenta separates (rips away) prematurely from the wall of the uterus -> leading cause is abdominal trauma (MVA or falls) -> surgical emergency
• in placenta previa, the placenta develops over and covers the cervix -> infrequently an emergency

Question 22

diabetes

Answer 22

• develops during pregnancy in many women who have not had it previously
• gestational diabetes will clear up after delivery (some can continue)
• treatment is the same as for any other patient with diabetes
• diet, exercise, or insulin injections

Question 23

special considerations for trauma and pregnancy

Answer 23

• with a trauma call involving a pregnant patients, you have 2 patients:
• the women
• the unborn fetus
• any trauma to the women has a direct effect on the fetus

Question 24

blood volume and heart rate

Answer 24

• pregnant women have an increased amount of overall total blood volume and a 20% increase in heart rate
• may have a significant amount of blood loss before you will see signs of shock
• uterus in vulnerable to penetrating trauma and blunt injuries
• larger than normal abdominal cavity -> hides blood

Question 25

assessment and management

Answer 25

• your focus is on the women
• suspect shock based on the MOI
• be prepared for vomiting and aspiration (medicine for pregnancy nausea is different for nonpregnant)
• attempt to determine the gestational period to assist you with determining the size of the fetus and the position of the uterus
• fetal depression the vena cava -> limited venous return -> obstructive shock -> never lay pregnant patient supine
• lay left lateral recumbent
• 1. have you felt the baby move or kick or 2. use a fetal doppler ? -> no risk or demise**

Question 26

cavities you can bleed to death in

Answer 26

• retroperitoneal cavity
• both femurs
• head
• street
• chest
• abdomen

Question 27

history taking

Answer 27

• investigate the chief complaint
• ask questions that will help you identify the cause of her complain and the associated signs and symptoms
• obtain a thorough obstetric history:
• her expected due date
• any complications that she is aware of (high risk factors)
• if she has been receiving prenatal care
• her thorough medical history (past OB history -> have many pregnancy, how many delivered, how many delivered to term, how many vaginally, how many c-section, how many elective/spontaneous abortions)
• GNP- grava (times pregnant) and para (delivered)

Question 28

obtain SAMPLE history

Answer 28

• do not focus only on the pregnant history
• determine the due date, frequency of contractions, a history of previous pregnancies and deliveries, the possibility of twins, and if she has taken any drugs or medications
• if her water has broken, ask whether the fluid was green (what color and does it have an odor)
• green fluid is due to meconium (fetal stool)
• the presence of meconium can indicate newborn distress, and its possible for the fetus to aspirate meconium during delivery

Question 29

physical examinations

Answer 29

• fetal movement- sign of distress and viability
• assess the major body systems
• for a pregnant in labor, focus, on contractions and possible delivery
• if you suspect that delivery is imminent check for crowning (by eye)

Question 30

vital signs

Answer 30

-Include pulse; respirations; skin color,
temperature, and condition; and BP
-Pay attention to tachycardia and hypotension or hypertension.
-Hypertension, even mildly elevated BP, may indicate more serious problems

Question 31

breech delivery*

Answer 31

• the presentation is the position in which an infant is born or the body part that is delivered first
• frank breech- butt presentation
• most infants are born head first
• occasionally, the buttocks are delivered first
• can delivered breech if the practitioner knows how to

Question 32

presentation complications

Answer 32

• limb presentation- breech

- on rare occasions the presenting part of the infant is neither the head nor but but a single arm, leg, or foot

Question 33

prolapse of the umbilical cord

Answer 33

• must be treated in the hospital
• umbilical cord comes out of the vagina before the infant
• rupture can happen
• abruptio placentae- can cause
• fetus compress umbilical cord -> cuts off oxygen -> no nutrients, bradycardia, fetal demise,

Question 34

infants head will compress the cord and cut off circulation

Answer 34

• do not push the cord back into the vagina
• put in knee chest position
• Trendelenburg’s position
• insert your gloved hand into the vagina, and push the infants head away from the umbilical cord

Question 35

postterm pregnancy

Answer 35

• 37-42- term
• 36 and earlier- preterm
• 42 and greater- post term
• infants can be larger, sometimes weighing 10 ib or more
• 22-24 weeks - viability
• can lead to problems with the mother and infant: a more difficult labor and delivery

Question 36

postterm pregnancy problems

Answer 36

• increased chance of injury to the fetus
• most common injury is shoulder dystocia- as shoulders come up against pubic bones while being born -> uterine contraction pushes down on the child and brachial plexus -> developmental issues
• increased chance of cesarean section
• women is at risk for perineal tears and infection
• infants have increased risks of meconium aspirations, infection, and being stillborn
• infants may not have developed normally

Question 37

fetal demise

Answer 37

• you may deliver an infant who died in the mothers uterus before labor
• onset of labor may be premature, but labor will progress normally in most cases
• if an intrauterine infection caused the demise you may note a foul odor
• do not attempt to resuscitate an obviously dead infant

Question 38

postpartum complications

Answer 38

• bleeding that exceeds 500mL is considered excessive
• can be measured by the amount of pads bled through
• continue to massage the uterus after delivery
• check your technique and hand placement if bleeding continues
• excessive bleeding is usually caused by the uterine muscles not fully contracting
• oxytocin is administered externally to help
• uterine contraction can be most helpful way to control internal hemorrhage postpartum
• continue massaging the uterus and cover the vagina with a sterile pad
• change the pad as often as possible
• do not discard and blood soaked pads
• place the women in the shock position, administer oxygen, monitor vital signs, and transport her immediately
• hysterectomy might be necessary if bleeding out

Question 39

embolism- postpartum complication

Answer 39

• hypercoagulapathic
• most commonly and pulmonary embolism
• results from a clot that travels through the bloodstream and becomes lodged in the pulmonary circulation
• the obstruction will block blood flow to the lungs and is potentially life threatening
• DVT- deep vein thrombosis
• encourage to walk around