Obstetrics Flashcards
Afterbirth
Placenta and membranes that are expelled from the uterus after the birth of the child
Umbilical cord
Extension of the placenta; 2 feet long; one vein (oxygenated blood to fetus) and two arteries- fetal lifeline
Amniotic sac
Protective sac; contains fetus and fluid
Amniotic fluid
Approx 500-1,000 mL from week 20 to 40; fluid for movement, protection, room for growth; fluid moves across placenta and is ‘changed’ constantly - should be CLEAR
Placenta
Organ of pregnancy- develops 14 days
1.) transfers heat
2.) exchange oxygen/carbon dioxide
3.) delivers nutrients
4.) carries away wastes
5.) endocrine gland- hormone production
A.) estrogen (prevents menses)
B.) progesterone (maintains pregnancy)
C.) human chorionic gonadotropin (hCG) (maintains progesterone production)
6.) barrier against most harmful substances (except narcotics, steroids, antibiotics)
Fetal Growth
End of 3rd month
12 weeks
Sex maybe distinguished
Heart is beating
Every structure found at birth is present
Fetal growth
End of 5th month
20 weeks
Fetal heart tones (FTH) can be detected - rate 120-160 bpm
Fetal movement my be felt by mother
Fetal growth
End of 6th month
24 weeks
Maybe capable of survival if born prematurely
Age of viability 22-24 weeks (varies)
Fetal growth
End of 9th month
Considered full term 37 weeks
Preterm before 37 weeks
Maternal changes
Reproductive system
Uterus increases in size
Vascular system
Formation of mucous plug in cervix
Estrogen causes vaginal mucosa to thicken
Breast enlargement
Maternal changes
Respiratory system
Bronchodilation
Increase in oxygen consumption
Increased tidal volume
Slight increase in respiratory rate
Maternal changes
Cardiovascular system
🔹Blood volume increases 40% - 50%
🔹Heart rate increases 10 - 15 bpm
🔹Blood pressure decreases by 2nd trimester = 10 - 15 mmHg systolic
▪️increase 3rd trimester to normal level
🔹Venous distention= risk for DVT and pulmonary embolism
🔹Supine hypotension- gravid uterus lies on inferior vena cava, decreasing venous return
▪️compression on abdominal aorta, pelvic and femoral vessels contribute to edema and varicose veins
▪️postural hypotension, syncope
▫️position left lateral recumbent during transport
🔹Cardiac output increases by 30% by week 34- cardiac pt’s have additional stress on heart
🔹Relative anemia- increase in RBC’s, need for more IRON- prenatal vitamins important
▪️risk for preterm labor or miscarriage
Volume loss of any kind➡️mother compensates ➡️ HR and BP little changes = FETUS in danger!
Maternal changes
Gastrointestinal system
Hormone levels- nausea/vomiting and peristalsis is slowed- bloating, constipation
Maternal changes
Musculoskeletal system
Loosened pelvic joints; prepares for delivery = Falls
Prenatal
Antepartum; existing or occurring before birth
Postpartum
Time after delivery
Gravidity
Number of pregnancies (including current)
Para
Number of deliveries (twins/triplets, multiples = para 1)
T- # of Term deliveries >=37 weeks
P- # of Premature deliveries >20 weeks; <37 weeks
A- # of Abortions <20 weeks
L- # of Living children
Primi- 1st time Multi- more than 1 Nulli- not, none
Gestation
Time of intrauterine fetal development
40 weeks
Trimesters
3 month intervals (3 trimesters in complete pregnancies)
Fetal death
No signs of life; obvious (err on the side of resuscitation efforts if in doubt)
Due date
Estimated date of confinement (EDC)
🔹figure first day of LMP plus 7 days➡️ minus 3 months (add the next year)
LMP= 8 May 2009
+1 year = 8 May 2010
-3 months = 8 February 2010
+7 days = 15 February 20010
Assess fundal height
Estimate gestation = 1cm per week
Between symphysis pubis and umbilicus= 12 weeks
At umbilicus = 20 weeks
Under xiphoid = full term**
Braxton-Hicks Contractions
False labor that increases in intensity and frequency but does not cause cervical changes
Stages of labor
Stage 1
Dilation
🔹onset of regular contractions to complete cervical dilation (opened) and effacement (muscle thins out)
🔹cervix is 10 cm dilated and paper-thin
🔹bloody show (mucus plug expels)
🔹primiparous-12.5 hr; multiparous- 7 hr
🔹contractions = beginning of one to beginning of next; duration = how long they last
▪️closer to stage 2 - contractions more frequent and duration longer
Stages of labor
Stage 2
Expulsion- full dilation to expulsion of newborns
🔹infant moves down birth canal, mother urge to push
🔹primiparous- 80 min; multiparous - 30 min
🔹crowning- presentation
Stages of labor
Stage 3
Placental- immediately after infant delivered to delivery of placenta
🔹do not delay transport during this stage
🔹approx 20-45 min
Field delivery
🔹Set up delivery area. (Know contents of OB kit)
🔹Give oxygen to mother and start IV-NS TKO (if time permits)
🔹Position mother - Lithotomy
🔹Drape mother
🔹As head crowns, apply gentle pressure- control head; avoid explosive delivery
🔹Typically- crowning infant face down (vertex) ➡️ turns to side
🔹Observe/correct nuchal cord
🔹Suction the mouth and then nose (only when necessary)
🔹Guide head downward to deliver upper shoulder; guide body/head upward to deliver lower shoulder
🔹Dry infant at level of vagina until cord is cut
🔹Clamp and cut cord. 4” and 6” ➡️ re-clamp end if bleeding continues
🔹Deliver the placenta and save for transport with the mother
Intact amniotic sac
During delivery ➡️ pinch and twist the amniotic sac to break it. Fluid will GUSH!
Prepare for rapid delivery!
Prolapsed cord
🔹The umbilical cord precedes the fetal presenting part
🔹Knee-chest position coy in Trendelenberg
🔹High flow oxygen and keep warm
🔹Umbilical cord is seen in vagina
▪️Insert two gloved fingers to raise the fetus off the cord. Do not push back. Cord pulse.
🔹Wrap cord in sterile moist dressing
🔹Transport immediately; do not attempt delivery
Neonate care
🔹Support the infant’s head and torso, using both hands (football carry)- slippery!
▪️Do not use axilla to hold infant! Brachial plexus injury =Erb’s Palsy
🔹Check airway - suction again only if necessary
🔹Dry, warm, position on side- dry blankets!
Stimulate- drying ➡️ flick feet, rub back
🔹Assess APGAR score- at 1 and 5 min; score 0, 1, 2
Acrocyanosis
Pink body, blue extremities normal at delivery
APGAR Score
A- Appearance (color)= blue 0; acrocyanosis 1; pink 2
P- Pulse (feel at umbilicus)=absent 0; <100 1; >100 2
G- Grimace (irritability)= none 0; grimace 1; cough, cry, sneeze 2 (when suctioning)
A- Activity (muscle tone)= limp 0; some flexion 1; active 2 (when straighten arm, leg)
R- Respiratory effort= absent 0; slow, irregular 1; strong cry 2
APGAR <6 requires resuscitation
Care of mother
🔹May shiver or tremble, VERY tired- normal
🔹Monitor BP; keep warm, watch for shock
🔹Blood loss- post partum- rush of blood after delivery- slows to a trickle
Postpartum hemorrhage
🔹Loss of >500 mL of blood following delivery
▪️Lack of uterine tone- soft (Tone)
▪️Vaginal or cervical tears (Trauma)
▪️Retained pieces of the placenta (Tissue)
▪️Clotting disorder (Thrombin)
🔹Large baby, placenta previa, abruptio placenta, prolonged labor
🔹ABC’s, O2 NRB
🔹Infant to breast
🔹Fundal massage- fingers flat against uterus above pubic bone; massage in circular motion = painful
🔹2 large-bore IV’s
🔹Administer oxytocin per physician’s order
🔹Do not pack Vagina- OB pads; Expedite transport
Complicated delivery
Breech presentation
🔹Buttocks, feet present first
🔹If delivering (shoulders most difficult)
▪️Support infant on forearm- support legs, pelvis; don’t grasp around abdomen
▫️deliver to umbilicus; try to extract 4-6” of cord for slack
▪️rotate gently to anterior/posterior shoulder placement
▪️Guide upward; then downward as normal delivery
▪️Ease head out
🔹If head does not deliver:
▪️Mother in knee-chest position (on back, elevate torso with pillows; knees pulled to chest)
▪️Create an airway- form a “V” - 2 fingers
▪️Push the vaginal walk away from infant’s face
▪️Lift body upward to assist head delivery
▪️Fails- rapid transport!
Complicated Delivery
Limb presentation
Place mother in knee-chest position, administer oxygen, and transport immediately. Do not attempt delivery.
Complicated Delivery
Multiple Births
🔹Most mothers know; some may not!!
🔹Follow normal guidelines, but have additional personnel and supplies
🔹40% are premature; Babies typically smaller
🔹Prevent hypothermia; monitor for respiratory difficulties
Complicated Delivery
Cephalopelvic Disproportion
🔹Infant’s head is too big to pass through pelvis easily
🔹Causes: oversized fetus, hydrocephalus, conjoined twins, or fetal tumors
🔹Unrecognized: can cause uterine rupture
🔹Usually requires cesarean section; Give oxygen to mother and start IV; rapid transport
Complicated Delivery
Shoulder Dystocia
(Can cause Erb’s Palsy)
🔹Infant’s shoulders trapped under mother’s pelvic bone causing Turtle sign
🔹Do not pull on the infant’s head; If baby does not deliver, transport the pt immediately
🔹Mother in knee-chest position
OB Complications
Hypertension Disorders
Chronic (Essential) Hypertension
Greater than 140/90 prior to pregnancy, before 20th week
Risk of stroke, miscarriage
OB Complications
Hypertension Disorders
Gestational Hypertension
Pregnancy induced HTN- after 20th week; resolves after delivery
Early sign of preeclampsia
OB Complications
Hypertension Disorders
Preeclampsia
(Toxemia of pregnancy)
🔹Gestational Hypertension ➡️ pregnancy induced HTN
🔹First birth, multigravida, excessive amniotic fluid; >35 y/o; HTN, twinning, diabetics, renal Dz
🔹Risk of Abruptio placenta (if progresses to eclampsia)
🔹Two of the following
▪️BP >140/90; or sudden rise Sys >20, rise Dias. >10
▪️Fluid retention/weight gain/edema
▪️Protein in urine= proteinuria
🔹H/A; N/V; visual disturbances (spots in vision); edema feet, face, hands; epigastric pain
🔹Hydralazine (Alpresoline) home medication
🔹**Symptoms may persist for up to 4-6 weeks after delivery
OB Complications
Hypertension Disorders
Eclampsia
🔹HTN and seizures!!
🔹Assume pregnancy with seizures is eclampsia until proven otherwise (Assess pt’s history!)
▪️Left lateral recumbent
▪️Calm, lights dim, NO lights/sirens
▪️O2, IV NS
▪️Seizure or postictal
▫️Magnesium Sulfate 2-5 g in 50-100 mL NS; slow IVP
▫️Diazepam 5-10mg IV/IM refractory to magnesium
▪️Monitor for abruptio placenta or pulmonary edema
▪️Transport for immediate C-section and NICU
[Consider Calcium gluconate 5-8 mL slow IV for respiratory depression from high doses of magnesium]
OB Complications
Gestational Diabetes
🔹Inability to process carbs during pregnancy; Mother ⬆️ resistance to insulin
▪️Polydipsia, polyphagia, polyuria
▪️Controlled- Diet, oral hypoglycemic, Insulin
▪️Resolves postpartum
▪️Field Tx- for hypo-, hyperglycemia
▪️Large infant at delivery ➡️ complications
OB Complications
Supine Hypotensive Syndrome
(Vena caval syndrome)
🔹Fetus presses on inferior vena cava ➡️ Reduces cardiac output
▪️Treat - left lateral recumbent position, elevate right hip, tilt backboard 15-30 degrees to the left
▪️Monitor fetal heart tones & maternal vital signs
▪️If volume is depleted, consider 2 large bore IV NS
▫️Orthostatic VS, skin tenting
OB Complications
Hyperemesis Gravidarum
Severe morning sickness
N/V, dehydration, electrolytes
Transport- ABC’s; IV fluids
OB Complications
Infection
Rubella, varicella, STD➡️ harm mother or fetus
UIT➡️ streptococcus ➡️ migrate to amniotic sac ➡️ preterm labor
Premature rupture of membranes- ⬆️ risk infection
Transport- ABC’s, Tx septic shock prn
Bleeding Pregnancy
Abortion
🔹Termination of pregnancy before the 20th week of gestation ➡️ ANY CAUSE
🔹Complete- all products of conception evacuated from the uterus
🔹Incomplete- fetus expelled, some tissues remain in uterus = complications
🔹Spontaneous (commonly called miscarriage)- Occur before 20th week; fetal or maternal defects
🔹Therapeutic- End pregnancy as thought necessary by a physician
🔹Septic- Presence of infection
🔹S/S- cramping, abdominal pain, backache, and vaginal bleeding
▪️Treat for shock; orthostatic vital signs
▪️Collect and transport passed tissue & Provide emotional support
Bleeding Pregnancy
Ectopic Pregnancy
🔹Assume- female of childbearing age ➡️ sudden or severe lower abdominal pain
🔹Radiate to back, amenorrhea
🔹Bleeding ➡️ Absent, minimal
▪️Rupture = excessive bleed + shock
🔹Risk: adhesions, PID, tubal ligation, IUD use
🔹Ectopic Pregnancy is life threatening
🔹2 large bore IV’s, Trendelenburg, surgery
Third Trimester Bleeding
Placenta Previa
▪️Painless- without contractions ▪️Bright red bleeding ▪️Recurrent or spotting 🔹Never attempt a vaginal exam 🔹Treat for shock. Transport immediately 🔹Risks: ⬆️ Age; multiparity; C-section; intercourse; preterm births
Third Trimester Bleeding
Abruptio Placenta
🔹Premature separation of placenta from uterus
🔹Associated with hypertension, preeclampsia/eclampsia, trauma, ⬆️ Age, infection
🔹Complications: Fetal hypoxia and death
🔹Assessment:
▪️Painful uterine contraction with dark vag bleed
▪️Uterus becomes tender and board-like if hemorrhage retained (concealed)
▪️Shock inconsistent with minimal vag bleed
🔹Life threatening to mother and fetus
🔹Treat for shock; fluid resuscitation, FHT.
🔹Transport in left lateral recumbent position (right hip raised)
Bleeding Pregnancy
Uterine Rupture
🔹Tearing, or rupture, of the uterus. MOST common after onset of labor
🔹Risks: Previous C-section or uterine surgery; prolonged, obstructed labor; fetal abnormality
▪️Severe, sudden, shearing pain during strong contraction
▪️Complete rupture- pain stops
▪️Shock- rapid onset
▪️Uterus palpated as a hard mass; separate from fetus
▪️Concealed bleeding
▪️Fetal heart tones are absent; lack of fetal movement
🔹Treat for shock
🔹Give high-flow, high-concentration oxygen and start 2 large bore IV’s of NS
🔹Expedite transport
Preterm Labor
🔹Maternal factors
▪️CV disease, renal disease, diabetes, uterine/cervical abnormalities, maternal infection, trauma
🔹Placental Factors- Placenta Previa, abruptio placenta
🔹Fetal Factors- Multiple gestation, Excessive amniotic fluid, fetal infection
Tocolysis
🔹Process of stopping labor
🔹Fluid bolus
▪️Stops ADH and oxytocin secretion from posterior pituitary gland
🔹Magnesium sulfate to inhibit smooth muscle contractions
🔹Terbutaline-relax smooth muscle- Beta 2 agonist
