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Paramedic Capstone Subject - QUT > Topic 8 - Obstetrics > Flashcards

Topic 8 - Obstetrics Flashcards

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1
Q

Amniotic Fluid Embolism - Features

A

Sudden profound and unexpected maternal collapse associated with:

  • Hypotension
  • Hypoxemia
  • DIC
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2
Q

Amniotic Fluid Embolism - Pathophysiology - Entry and Phase 1

A

Can enter through placental implantation but most commonly through the endoservix

PHASE 1 - An anaphylactoid biochemical mediator response causing peripartum hypoxia, hemodynamic collapse and coagulopathy. Lasts about 30 minutes

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3
Q

Amniotic Fluid Embolism - Phase 2

A

PHASE 2 - occurs in patients that survive phase 1 – L ventricular failure, DIC and pulmonary edema

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4
Q

Amniotic Fluid Embolism - Causes of Cardiac dysfunction

A
  • Cardiac dysfunction is due to ischemia and the presence of endothelin (potent vasoconstrictor), histamine, PGs, Serotonins, Thromboxanes and leukotreins from the fluid
  • Vasospasm and shunting causes ARDS
  • Fluidalso contains coagulation factors and sloughed fetal skin which cause DIC without significant blood loss
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5
Q

Amniotic Fluid Embolism - Presentation

A

Breathlessness, cyanosis, hypotension, dysrhythmia, DIC, seizures, profound fetal distress

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6
Q

Amniotic Fluid Embolism - Mx

A
  • O2 –CPAP or PEEP
  • Fluidsand vasopressors
  • Coagulants
  • Fastdeliver of baby
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7
Q

Shoulder Dystocia - Principle

A

Disproportion between bisarcomial diameter of the fetus and anteroposterior diameter of pelvic inlet - confirmed if no delivery 60 seconds after head presents with normal downward traction

Around 1% of all vaginal births

C-section usually planned if >5kg or in instance of gestational diabetes

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8
Q

Shoulder Dystocia - Risk Factors (Weak)

A
  • Previous shoulder dystocia
  • Advanced maternal age
  • Malebaby
  • Macrosomia
  • Maternal diabetes
  • Maternal obesity
  • Prolonged 1st and 2nd stages of labor
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9
Q

Turtle’s Sign

A

Positive sign for shoulder dystocia - chin retracts into perineum

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10
Q

Aim of Emergency Manouvers in Shoulder Dystocia

A
  • Increase functional size of bony pelvis
  • Decrease bisacromial diameter of the fetus
  • Change relationship of bony pelvis with bisacromial size of fetus by rotation
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11
Q

McRoberts manouvre goal

A
  • Increases width of birth canal by reducing lumbosacral lordosis
  • Avoid fundal pressure
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12
Q

Chord management in shoulder dystocia

A
  • Avoid cutting chord early if possible – increases risk cerebral palsy and asphyxia -
  • Delay chord clamping if it has had sustained traction on it – increased transfer of blood to placenta may have occurred
  • If chord must be immediately divided – try milking chord quickly
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13
Q

Documentation in shoulder dystocia

A
  • Time of head birth
  • Maneuvers performed and timing
  • Direction baby is facing and which shoulder is impacted
  • Time of delivery
  • Staff in attendance
  • Condition of baby
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14
Q

Complications for mother in shoulder dystocia

A
  • 3rd/4th dergree tears
  • PPH
  • Uterinerupture
  • Futureissues
  • Physcological obstetric effects
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15
Q

Complications for baby in shoulder dystocia

A
  • Brachial plexus injury
  • Fractured hummers/clavicle
  • Hypoxia (pH drops .04 per minute)
  • Death
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16
Q

Umbilical cord prolapse

A

· Chord below or beside presenting part

· Life threatening:

  • Chord compressed – vessels within cord spasm
  • O2 can be prevented from reaching the fetus
  • Mx is complicated due to ongoing contractions - more compressive force
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17
Q

Cord prolapse management

A
  • Immediate transport
  • May only survive 10 min – no O2
  • 15L/minO2
  • Positioning ‘knee-to-chest’ of mother to reduce cord pressure
  • If cord not pulsating or fetal distress present – push presenting part off chord
  • Cover cord with sterile moist towel/dressing – avoid handling
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18
Q

Nuchal cord

A
  • Up to 25% birth
  • Can be looped up to 4 times
  • If cord is needed to be cut – time criticaldelivery
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19
Q

Breech birth types

A
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20
Q

Breech birth risk factors

A

Most significant factors are preterm labour and gravida however also:

  • Previous breech
  • Low-lying placenta/praevia
  • Pelvic masses
  • Bicornuate uterus
  • Polyhdraminios
  • Oligohydraminios
  • Fetal abnormalities
  • Twins or higher multiples
  • Grand multiparty
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21
Q

Breech management

A
  • Loveset’s
  • Marceau-Smellie-Viet
  • Burns–Marshall method
    • Not recommended
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22
Q

Hematomas during delivery

A

Vulvul - usually varicose veins

Vaginal - potential space for 2 liters of blood

Broad Ligament - level of shock is out of proportion with the amount of blood seen

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23
Q

Uterine rupture

A

A tear in uterus usually associated with:

  • Previous caesarian section
  • Other uterine surgery
  • Grand multiparity
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24
Q

Managment of uterine rupture

A
  • O2
  • Appropriate positioning
  • Fluid
  • Pain relief
  • Notification receiving hospitaland urgent transport
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25
Q

Classifications of uterine rupture

A

ACUTE - less than 24 hours post delivery

SUBACUTE - from 24 hours to 4 weeks

CHRONIC - 4 weeks onwards

INCOMPLETE - fundus reaches servic

COMPLETE - fundus passes through cervix

PROLAPSE - uterus visible from vulva

26
Q

Uterine prolapse

A
  • Occurs spontaneously or following excessive traction being applied to the umbilical cord
  • Severe abdo/pelvic pain due to excessive traction on the broad ligament and ovarian ligaments
  • Hemorrhage if placenta is partially separated
  • Manifestations of shock are more common with complete uterine inversion
27
Q

Management of uterine inversion

A
  • Cover uterus with sterile dry drape –minimize infection
  • Help women achieve a position of reasonable comfort
  • Administer pain relief as appropriate
  • Treat for hypervolemia
  • Transport to definitive care
  • Notify
28
Q

Secondary PPH

A
  • 24hrs to 6 wks
  • High association with maternal morbidity –85% require admission

Aetiology:

  • Unknown in one third of cases
  • Subinvolution of the uterus – does not return to normal size
  • Retained products
  • Endometriosis
29
Q

Characteristics of secondary PPH

A
  • Ongoing vaginal bleeding
  • Pallor from recent blood loss
  • Change in lochia – regression to bright red and increasing amounts – if infection, smell may be offensive
  • Uterus may be larger than expected –failure to contract
  • Pyrexia
  • Tachycardia – indicates infection or hypervolemia
30
Q

VTE risk factors

A
  • >35
  • Obesity
  • Parity >4
  • Family Hx
  • Gross varicose veins
  • Major concurrent illness
  • Prolonged bed rest >4 days
  • Long-haul travel
  • C-section
  • Prolonged labor
31
Q

VTE diagnosis

A
32
Q

VTE management

A
  • Transport critical
  • O2 Analgesia
  • IVresus. as required
  • Positioning to prevent mobilisation of clot
33
Q

Risk factors for prolapse

A
  • Abnormla fetal presentation
  • Multiparity
  • Low birth weight
  • Prematurity
  • Polyhydramnios
34
Q

Complications to anticipate durring shoulder dystocia (for mother and baby)

A

MOTHER:

  • PPH
  • Perineal trauma
  • Psychological trauma

BABY:

  • Birth trauma
  • Hypoxia
35
Q

APGAR

A
36
Q

Pertinant extra history questions in obstetric cases

A
  • How many weeks pregnant (?/40)– Due date
  • Need to ascertain G and P
  • Previous obstetric history (ifany) especially in relation to birthing problems and/or premature births.
  • Has the patient had antenatal care/assessment and/or recent scans
  • Any identified risks such as breech, malposition, placental abnormalities
  • Enquire about foetal movements, show, amniotic fluid presentation (presence of meconium)
37
Q

When do ectopic pregnancies generally rupture?

A

Rupture usually occurs between 6 and 8 weeks of gestation: Can occur as early as 5 weeks or as late as 14-16 weeks

38
Q

Risk factors for ectopic pregnancy

A
  • In virto fertilisation
  • STIs
  • Use of intrauterine devices
  • Advanced maternal age
  • Smoking
  • Previous Hx of ectopic pregnancy
39
Q

Pre-eclampsia

A
  • > 140mmHg SBP with protenuria and altered liver function
  • Most likely due to vasospasm due to:· Increased resistance to blood flow leading to multi-system organ damage
  • Usually after 20 weeks
  • Hypertension in pregnancy = 140/90
40
Q

Triad of pre-eclampsia

A
  • Hypertension
  • Proteinuria
  • Generalized edema
41
Q

Management for pre-eclampsia

A
  • Seizure management (ICP)
  • Reduce external stimuli
  • Transport to an appropriate facility
42
Q

Abruptio placentae types

A

PV bleeding may only present in partial abruption

43
Q

Abruptio placentae presentation

A
  • Pain
  • Bleeding
  • Shock
  • Abdominal rigidity
  • Difficulty hearing fetal heart sounds
44
Q

Common causes of abruptio placentae and risk factors

A

Usually abdominal trauma - increasingly frequent as pregnancy progresses

Risk factors may include gestational hypertension, previous Hx of abruption, Hx of c-section, intrauterine infection and tobacco and cocaine use

45
Q

Complications from abruptio placentae

A
  • Death
  • Maternal hypovolemia
  • Acute renal failure
  • Coagulopathies
46
Q

Placenta previa and risk factors

A
  • Abnormal placental implantation
  • Risk factors include:
    • Parity
    • C-section
    • Maturing age
    • Smoking
    • Previous placenta previa
47
Q

Placenta previa grades

A
48
Q

Presentation features of placenta preavia

A
  • Vaginal bleeding – usually bright red/profuse
  • Signs of shock
  • No abdominal pain - unprovoked by bleeding or intercourse
  • In contrast with abruption hemorrhage is uncontrolled, principal problem is hypervolemia rather than fetal hypoxia however fetal hypoxia will ensue maternal hypotension
49
Q

Postpartum hemorrhage defintions

A

500 mls or more (arbitary quantity) or a loss that if left untreated can lead to maternal shock and death. Occurs within the first 24 hours but usually 20-60 minutes of birth

50
Q

4 most common causes of postpartum hemorrhage

A
  1. Auterine Atony (tone) (70-90%) - failure of adequate myometrial contraction after placenta expulsion. Related to overstretched uterus, previous hemorrhage and use of muscle relaxants as risk factors
  2. Retained placental tissue (tissue) - risk factors include multiparity, previous uterine surgery or infection
  3. Trauma to genital tract (trauma) (uterine rupture or inversion, cervical laceration and previous eclampsia)
  4. Coagulation disorders (thrombin)
51
Q

Feotal viability in maternal cardiac arrest

A

5 minutes in arrest and fetus is potentiallyviable – consider emergency hysterectomy

Not before 23 weeks – will not improvemothers heamodynamic condition

52
Q

HELP Syndrome

A
  • Haemolysis, elevated liver enzymelevels, and low platelet count
  • Classic triad of:
    • Abnormal vascular tone
    • Vasospasm
    • Coagulation defects
  • Vision changes are also common
53
Q

HELP syndrome pathogenesis

A
  • Haemolysis causes platelet aggregation and microvascular endothelialdamage – leads to Haemolytic anaemia
  • Hepatic Damage – hepatic restriction to blood flow cause RUQ pain
  • Platelet aggregation causes thrombocytopenia
54
Q

Trauma in pregnancy - key considerations

A
  • Motheroften remains hemodynamically stable whilst shunting blood away from fetus
  • O2 disassociation moved to left fetus§ Increased blood volume and CO means signsof shock are late and are severe when present
    • Fundal height important to determine fetalviability (likely if above umbilicus)- If it increases – is also a sign of concealed abruption
  • If <20 weeks treat as if not pregnant
  • In burns – larger SA and more important to maintain normotension
55
Q

Gestational diabetes

A
  • Thought to be related to inability of mother to metabolize carbohydrates
  • Eitherdeficiency in insulin or hormones that block maternal insulin (resistance)
56
Q

Stages of labour

A
  1. Onset of regular contractions to completecervical dilation
  2. Expulsion of newborn
  3. Placenta delivery

Regular contractions lasting 45-60s every 1-2 minutes = no time to transport

57
Q

Ductous venous, foraman ovale and ductus arteriosus

A

Ductous venous - Empties directly into inferior vena cava, bypassing the immature liver

Formaram ovale - Shunts 1/3 of blood from R atrium to L atrium, bypassing pulmonary trunk

Ductous Arteriousus - Pumps blood that does enter pulmonary trunk directly into aorta

58
Q

Primary PPH management

A
59
Q

Spontaneous abortion w/ fetal presentation

A
  • Spontaneous loss of pregnancy before 20 weeks (or 400grams)
  • Cut/clamp chord and wrap
  • Resus is futile <23 weeks or <400g
60
Q

Pre-eclampsia diagnostic criteria

A
  • Systolic BP >140mmHg or Diastolic >90mmHg

+

  • Neurological problems
  • Proteinuria
  • Renal insufficiency
  • Liver disease
  • Hematological disturbances
  • Fetal growth restriction
61
Q

Spontaneous abortion management

A
  • Cut and clamp chord
  • Wrap feotus
  • If gestational age <23 weeks or birthweight <400grams
  • Manage for sepsis and hemorrhage

Paramedic Capstone Subject - QUT (12 decks)

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