Week 2- Complications of Pregnancy and Delivery Flashcards
How would you identify a problem with an OB patient?
- Bleeding
- Foul smelling amniotic fluid
- Decreased LOA
- Prolapse, anything hanging out
- Fever
- Hypotension, hypertension, bradycardia, tachycardia
- No fetal movement
- Excessive discharge
- Changes in vital signs
- Any abdo pain
What are some risk factors the affect pregnancy?
Maternal Risk Factors:
- Being older than 35
- Being younger than 20
- Smoking cigarettes and drinking alcohol
- Being pregnant with twins, triplets or more
- Having a history of miscarriage
- Obesity or anorexia
What are some health conditions that can complicate pregnancy?
- Diabetes
- Cancer
- High BP (this can stop the placenta from getting enough blood)
- STI’s
- Kidney problems
- Epilepsy
- Anemia
What are some 1st trimester complications?
- Ectopic pregnancy
- Miscarriage
- Hyperemesis
What is Ectopic pregnancy?
- A condition where fertilized egg implants outside your uterus (usually in your fallopian tube 90%)
- Other area include: at the end of tubes- close to ovaries, abdo cavity, low in cervix
- Diagnosed before <12 weeks, occur most often at 6 weeks
What are some causes of ectopic pregnancy?
- Often occurs to damaged fallopian tubes
- Pelvic inflammatory disease (swollen tubes)
- Intrauterine device
- Previous ectopic pregnancy
- Advanced maternal age
- Tobacco
What is the classic triad of ectopic pregnancy?
- Pain
- Amenorrhea (missed periods)
- Vag bleeding
What are the s/s of ectopic pregnancies?
- When ruptured will present with hypotension and shock
- Due to blood in the peritoneal cavity, there may be complaints of shoulder pain due to irritation and this can also cause bradycardia or lack of tachycardia in hypovolemic pt
How do we treat an ectopic pregnancy pt?
- Treat for shock
- IV fluids
- Oxygen
What is miscarriage (spontaneous abortion)?
- The loss of pregnancy naturally before 20 weeks (most happen in 1st trimester)
What causes most miscarriages?
- Chromosomal problems
What is the common treatment for miscarriages?
- Surgical intervention common treatment- dilation and curettage, this removes remaining tissue from inside uterus to prevent infection or vag bleeding
How does miscarriage in a pt present?
- Often presents with bleeding, which can be light with clots and tissue and cramping
- Occurs for approx 1 week
- Can also be massive bleeds with hypovolemia
How do you treat a miscarriaged pt?
- IV fluids
- Oxygen
- Treat for shock
What is hyperemesis gravidarum?
- Severe nausea and vomiting during pregnancy
- Vomiting >3 times/day
- Can lead to dehydration
- Vertigo
- Weight loss
- Preterm labor
How do you treat a pt with hyperemesis gravidarum?
- IV fluids
- Oxygen
- Ondansteron or dimenhydrinate
What are some 2nd and 3rd trimester complications?
- Preeclampsia
- Eclampsia
- Gestational diabetes
- Placenta previa
- Abruptio placenta
What is preeclampsia?
- Is a hypertensive disorder, that occurs after 20 weeks
- Can also develop up to 10 weeks after delivery
What are s/s of preeclampsia?
- High BP >140/90
- Severe headache
- Blurred vision
- Upper abdo pain
- N/V
- Proteinuria
- Edema
What is eclampsia?
- When a person with preeclampsia goes into a seizure
How to treat a pt with eclampsia/ preeclampsia?
- Treat for seizure, manage airway (eclampsia)
- Treat for N/V
- Bring to the hospital
What is gestational diabetes?
- Diabetes caused by pregnancy due to carbohydrate metabolism
- Mother is unable to produce and use all the insulin required
- Oral hypoglycemic drugs are contraindicated due to their safety profile in pregnancy
- One baby is delivered, condition often resolves, but can reoccur later in life
What are the s/s of gestational diabetes?
- Increased thirst
- Frequent urination
- Nausea
- Fatigue
- Sugar in urine
- Frequent bladder and skin infections
- Yeast infections
- Blurred vision
- Drt mouth
What is placenta previa?
- When the placenta partially or fully covers the cervix; this is easy to detect on u/s
- Can occur when blastocyst implants too close to cervix
- Fetus will be unable to deliver vaginally if placenta is fully covering the cervix
- Bleeding is normally bright red and painless
- Delivering fetus can rupture placenta causing massive blood loss
What are ths s/s of placenta previa?
- Asymptomatic
- Painless bleeding bright red
What is abruptio placenta?
- Partial/ full detachment of placenta at 20 weeks; occurs when vascular structures are torn away from uterine lining
Abruptio Placenta pt presentation?
- Can cause significant occult (concealed) bleed or can present as vag bleeding
- Pt has complaint of severe abdo pain, sometimes describes as tearing
Abruptio placenta risk factors include:
- Trauma
- Multiple fetuses
- Short umbilical cord
- Previous c-section
- Preeclampsia/ eclampsia
What are the s/s of abruptio placenta?
- Can include vag bleeding
- Contractions that don’t relax
- Abdo pain
What is amniotic fluid embolism (AFE)?
- AFE is when amniotic fluid, fetal cells, hair or other debris enters into the maternal pulmonary circulation, causing cardiovascular collapse
- Typically occurs in labour or 30 mins after delivery
What is the pt presentation of AFE?
- Pt may present much like a massive PE with dyspnea
- Increased WOB
- Hypoxia
- Hypotension
- Possibly cardiac arrest
Trauma in pregnant pt’s
- MVC’s, Assaults, and falls
- 60-70% of fetal loss is reported from minor injury.
- Seat belts are often worn improperly due to a fear of hurting the infant
What to remember when dealing with trauma?
- You’re treating 2 pt’s, not one
- Mortality of the infant relies on the mother, prehospital tx should be maximized for maternal survival
- In cardiac arrest, with a futile prognosis, ongoing CPR and transport should occur to a hospital cable of emergency c-section
Twins and Complications
- 40-50% will be preterm
- 2nd twin will often “Malpresentation due to significant room to move, once 1st infant is delivered
- Cord prolapse
- PPH- overdistension of the uterus may result in uterine atony. Higher incidence of mean blood loss with twins
When should medics clamp the cord with twins?
- After delivery of 1st twin Medic should not wait to clamp cord (medic will not know if placentas joined/ shared)
- Label clamp near umbilicus, so you know what infant was delivered first
How to sometimes tell it’s going to be twins?
- Smaller than anticipated birth weight; fetus is competing for space
- Fundal heigh remains high; b/c there is still a 2nd or more fetus in utero
- Fetal parts may be able to be palpated through abdo
What is considered a premature birth?
<37 weeks
- Always at risk of hypothermia; true for all neonates
- Usually requires resus
- Poor lung compliance (hard to squeeze BVM)
- No surfacant- alveoli not fully formed
What is nuchal cord?
- Check for cord- remove if present- slip over head or body- document of present
- If the cord is tight, it will impede delivery. Clamp/ cut cord and deliver infant quickly
- Prepare to deliver rest of baby/ shoulder are the hardest to deliver- downward for anterior shoulder & upward flexion “bum to bum”
What is precipitous labour?
Extremely rapid delivery:
- Delivery of baby within 3 hrs of regular contractions
- More common with 2nd births “multips”
- Rapid labour may increase risk of perineal lacerations & pph due to uterine atony
What is the management for precipitous labour?
- Same as delivery
- Reassure mom
- Encourage “panting” vs “pushing” to slow it down
- Place mom in a position where gravity isn’t working against you
- Guard perineum
- Control delivery of head- apply gentle “counter pressure” to vertex when crowning occurs
What is occiput anterior?
- Normal presentation
- Vertex presentation is what we hope for, it is the path of least resistance
What is occiput posterior?
- Fetal occiput is posterior in relation to the maternal pelvis “sunny side up”
Abdominal Examination for Occiput Posterior
- Abdo examination, the lower part of the abdo is flattened, fetal limbs are palpable anteriorly and the fetal heart may be heard in the flank
Vaginal Examination for Occiput Posterior
- The posterior fontanelle is towards the scrum and the anterior fontanelle may be easily felt if the head is deflexed
What are the malpresentations that will not deliver? (L&G)
- Tranverse lie= head and breech can be felt with exam of abdomen
- Shoulder presentation= shoulder is presenting part
- Oblique lie= fetus lies on a diagonal
In these scenarios inspect perineum to rule out cord prolapse or limb presentation
What to do with limb presentation?
- Do not push back in
- Discourage pt. from “pushing”- tell pt. to “pant”
- Wrap the limb & keep warm (L&G)
Birth not possible with this type of Limb Presentation
What is brow presentation?
- Caused by partial extension of the fetal head so that the occiput is higher then sinciput (front of skull, forehead to crown)
Abdominal examination with brow presentation
- More than half the fetal head is above the symphysis pubis and the occiput is palpable at a higher level than sinciput
Vaginal examination with brow presentation
- The anterior fontanelle at the orbits are felt
What is frank breech?
Most common
- Hips flexed and legs extended over the anterior surface of the body (best). Buttocks will be viewed from cervix
What is complete breech?
- Occurs when both hips and knees are flexed, therefore buttocks and feet enter cervix first
What is footling breech?
Will not deliver if knees locked on pelvic girdle
- One hips and knee flexes, while the other remains straight and enters the birth canal first.
- Buttocks and legs don’t provide an adequate wedge to open the birth canal; risks of cord prolapse is high
What are the signs of breech presentation?
- Premature
- Baby’s buttocks or lower extremities presenting
With breech presentation, what is the greater risk?
- Trauma
- Prolapse cord/ compressed cord
- Hypoxia
What is the management of breech?
- Try to deliver frank breech- bum/feet first
- Transport complete breech immediately
- Prepare to transport footling breech
Mother may have a strong urge to push with complete/ footling breech, but the cervix may not be fully dilated, therefore the head will get stuck; encouraging avoidance of pushing
Feet 1st Breech
- Place pt. into gravity position- side of bed, upright, or supported squat position
- Voiding may increase internal space for fetal descent
- An assistant should be applying gentle fundal pressure to keep the fetal head flexed
- Encourage pt. to push when presenting part visible- i.e. bum “hands off” to reduce stimulation to neonate to breath
Breech delivery emergent/ unplanned
- Consider delivery of legs- assess the need
- Gentle maneunvers
- Insert finger behind knee “popliteal fossa”
- flex knee
- abduct thigh
- legs will deliver
spontaneously - don’t touch cord
Delivering a breech:
- Assess need to assist delivery of arms
- Might need gentle release
- Keep allowing gravity to assist with descent
- “Do not pull if progressing”
When should you attempt the mauriceau-smellie-veit?
- Attempt MSV if the head doesn’t deliver within 3 mins of the body
What is the mauriceau-smellie-veit?
- Lay the neonate along one forearm with palm supporting the neonate’s chest and the two fingers exerting gentle pressure on the neonate’s fact to increase flexion
- Place other hand on the neonate’s back and with two fingers hooked over the shoulders and the middle finger pushing up on the occiput to aid flexion
- When hairline becomes visible, lift the body in an arc to assist the fetal head to pivot around the symphysis pubis and allow the face to be born slowly. If a 2nd paramedic is available, have them apply suprapubic pressure
- Lift body in “arc” to assist head delivery “bum to mom”
What is cord prolapse?
Load & Go
- Occurs when umbilical cord proceeds neonate thru the cervix (cord presents first). The umbilical cord will become compressed by the following neonate
What are the outcomes of cord prolapse?
- Can lead to fetal hypoxia or death secondary to cord compression. Between fetus & pelvis wall or wall of uterus
What is the management of cord prolapse?
- Explain the situation to the mother; need for C-section
- Assist pt. into “knee-chest” position
- Apply sterile gloves
- Gently assess the cord for pulse
- Strong pulse
a. replace cord into vagina
b. utilize min cord
handling to reduce
“vasospasm”
What is the tx if the cord has a weak pulse?
- Gently cradle in hand (Tell mom what you’re doing)
- Replace cord into vagina while inserting fingers into vagina & apply manual digital pressure on presenting part
- Lift presenting fetal part off cord to relive compression
- Cord pulse will become stronger if elevating presenting part
- You will keep your hand here for entire transport
- If delivery imminent, try to deliver quickly
- Prepare to resus neonate- especially if oxygen compromised by compressed cord
How do you transport a prolapse cord pt?
- May need to transport “knee-chest” position of strong contraction
What is pt’s position on stretcher for prolapsed cord?
- Exaggerated “sims” position
- Elevate hips to use gravity to help cord in
What is shoulder dystocia?
- Occurs when fetal shoulders are unable to born either spontaneously or with gentle flexion of head
- Impaction of anterior shoulder against symphysis pubis after delivery of the fetal head or posterior shoulder impacted against sacral promontory
What can occur at 4 min mark with shoulder dystocia?
- Critical irreversible hypoxic injury will occur at the 4 min mark once the head is born
Impacted shoulder risk factors:
- Prior shoulder dystocia
- Gestational diabetes
- Postdate deliveries
- Maternal short stature
- High pregnancy weight and weight gain
- Abnormal pelvic anatomy
- Previous instrumented delivery
What can you expect to see with shoulder dystocia?
- Large baby head
- Head stays occiput/ anterior
- Does not ease in restitution- “no or slow turn”
- Turtle sign
What are the maternal complications with shoulder dystocia?
- Soft tissue injuries
- Anal sphincter damage, cervical, or vaginal tears etc
- Uterine rupture
- PPH
What are the neonatal complications with shoulder dystocia?
- Clavicle fracture
- Fetal acidosis
- Humeral fracture
- Brachial plexus palsy- (transient/ permanent) Hypoxic brain injury
- Death
What is the acronym we use to treat shoulder dystocia?
ALARM
What does the first A stand for in ALARM?
-A= Ask for help
- you need a 2nd crew
What does the L stand for in ALARM?
-L= lift legs, hyperflex thighs (McRoberts Maneuver)
What is the McRoberts Maneuver?
- Hyperflex maternal hips (knee to chest position) and tell the pt to stop pushing. This widens the pelvic outlet by flattening the sacral promontory and increasing the lumbosacral angle
What does the second A stand for in ALARM?
-A= Adduct shoulder
- Apply suprapubic pressure
Suprapubic pressure= use palm or fist to press down on your abdomen just above your pubic bone. The pressure is applied downward assist to dislodge the impacted shoulder
What does the R stand for in ALARM?
-R= Roll over (Gaskins Maneuver)
- Gaskins maneuver- with the pt on her hand and knees (all 4’s)
- Gentle downward traction is applied to the posterior shoulder (the shoulder against the maternal sacrum)
- Upward traction is applied on the anterior shoulder
What does the M stand for in ALARM?
-M= Manual delivery of 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
What is postpartum hemorrhage?
- Obstetrical emergency and within the top 5 causes of maternal death
- Can occur right after delivery (Primary <24 hrs post delivery) or up to 12 weeks later (secondary)
- Bleeding may occur over several hrs
- May be diluted with urine & fluid
What is the man cause of PPH?
4 T’s
- Tone= exhausted uterus & cannot contract
- Tissue= parts of the placenta still retained & clotting compromised
- Trauma= uterine rupture/ lac during delivery
- Thrombin= coagulation abnormalities
How many L is the hemorrhage defined?
- 500ml or more severe PPH is 1L
What is Fundal Massage?
- Place one hand on lower abdo and use smooth circular movement to massage uterus
- 10-15 min, reassess
- Have mom empty bladder
- If bleeding conts after attempting uterine massage- go to bimanual compression
What is bimanual compression
- One hand above symphysis pubis & other on top of fundus
- Squeeze together- for 5-10 mins until bleeding stops
When should you preform bimanual compression?
- Placenta delivered and fundal massage fails
- Placenta hasn’t delivered and PPH is present= only bimanual
What is Meconium?
- Newborn’s first stool/ bowel movement
- This is sticky, thick, dark green poop is made up of cells, protein, fats and intestinal secretions, like bile
What should you do when meconium is observed?
- Report color to receiving staff
- Use bulb suction if required, wipe mouth and nose with gauze as required
- Provide resp support if required
- Provide routine care
