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ScenarioScenarioYour patient is G5P4 and due in 1 week with Your patient is G5P4 and due in 1 week with this pregnancy. She called 9this pregnancy. She called 9--11--1 because she 1 because she had painless vaginal bleeding, but by the time had painless vaginal bleeding, but by the time you arrive, contractions have begun and the you arrive, contractions have begun and the bleeding has increased. As you administer bleeding has increased. As you administer oxygen and start an IV, she becomes pale oxygen and start an IV, she becomes pale and complains of sudden, severe difficulty and complains of sudden, severe difficulty breathing. Her oxygen saturation drops to breathing. Her oxygen saturation drops to 84%.84%.
Amniotic Sac and FluidAmniotic Sac and FluidMembrane surrounding fetusMembrane surrounding fetus
Fluid from fetus: Urine, secretionsFluid from fetus: Urine, secretionsAccumulates rapidlyAccumulates rapidly175175--225 mL by 15th week225 mL by 15th weekAbout 1 L at birth About 1 L at birth
Rupture of membraneRupture of membraneWatery dischargeWatery discharge
Fetal Growth and DevelopmentFetal Growth and Development
GestationGestationPeriod during which intrauterine fetal development Period during which intrauterine fetal development takes placetakes placeAverage 40 wks from fertilization to deliveryAverage 40 wks from fertilization to delivery9090--day periods (trimesters)day periods (trimesters)
Obstetrical History Obstetrical History Length of gestationLength of gestationParity and gravidityParity and gravidityPrevious cesarean delivery Previous cesarean delivery Maternal lifestyle Maternal lifestyle Infectious disease statusInfectious disease statusPrevious gynecological or obstetrical Previous gynecological or obstetrical complications complications PainPain
General Management of OB PatientGeneral Management of OB Patient
If birth not imminent, care for healthy patient often If birth not imminent, care for healthy patient often can be limited to basic treatment modalitiescan be limited to basic treatment modalities
In absence of distress or injury, transport in position In absence of distress or injury, transport in position of comfort:of comfort:
Usually left lateral recumbentUsually left lateral recumbentECG monitoring, oxygen, and fetal monitoring may be ECG monitoring, oxygen, and fetal monitoring may be indicatedindicatedBased on assessment Based on assessment IV access in some patientsIV access in some patients
Greatest risk of fetal deathGreatest risk of fetal deathFetal distress and intrauterine demise caused by Fetal distress and intrauterine demise caused by trauma to mother or her deathtrauma to mother or her death
AssessmentAssessmentSigns of shock can be slow to developSigns of shock can be slow to developDecreased fetal movement/HR may indicate shockDecreased fetal movement/HR may indicate shock
Trauma in PregnancyTrauma in PregnancyManagementManagement
High concentration oxygen, administer fluidHigh concentration oxygen, administer fluidVasopressors not recommendedVasopressors not recommendedPrepare for laborPrepare for laborAggressive resuscitation if arrestAggressive resuscitation if arrestImmobilize and transport Immobilize and transport
PreeclampsiaPreeclampsiaUnknown causeUnknown cause
Often healthy, normotensive primigravidaOften healthy, normotensive primigravida•• After twentieth week, often near termAfter twentieth week, often near term
Characterized by:Characterized by:VasospasmVasospasmEndothelial cell injuryEndothelial cell injuryIncreased capillary permeabilityIncreased capillary permeabilityActivation of clotting cascadeActivation of clotting cascade
Preeclampsia and EclampsiaPreeclampsia and EclampsiaDiagnosis of preeclampsiaDiagnosis of preeclampsia
HypertensionHypertension•• Blood pressure >140/90 mm HgBlood pressure >140/90 mm Hg•• Acute rise of 20 mm Hg in systolic pressureAcute rise of 20 mm Hg in systolic pressure
OROR•• 10 mm Hg rise in diastolic pressure over prepregnancy 10 mm Hg rise in diastolic pressure over prepregnancy
levelslevelsProteinuriaProteinuriaExcessive weight gain with edemaExcessive weight gain with edema
AbortionAbortionTermination of pregnancy from any cause before 20Termination of pregnancy from any cause before 20thth
week of gestationweek of gestationLater is known as Later is known as preterm birthpreterm birth
Common classifications of abortionCommon classifications of abortion
Determine:Determine:Onset of pain and bleedingOnset of pain and bleedingAmount of blood lossAmount of blood lossIf any tissue passed with bloodIf any tissue passed with blood
Abruptio PlacentaeAbruptio PlacentaePartial or complete detachment of normally Partial or complete detachment of normally implanted placenta at more than 20 weeksimplanted placenta at more than 20 weeks’’gestationgestation
Placenta PreviaPlacenta PreviaPlacental implantation in lower uterine Placental implantation in lower uterine segment, encroaching on or covering cervical segment, encroaching on or covering cervical osos
1 in 300 deliveries1 in 300 deliveriesMore common in preterm birthMore common in preterm birth
Painless, bright red bleedingPainless, bright red bleedingIncreases if labor beginsIncreases if labor beginsFetal compromiseFetal compromise
Onset of regular contractionsOnset of regular contractionsEnds with complete dilation of cervixEnds with complete dilation of cervix
Stage 2Stage 2From full dilation of cervix to delivery of infantFrom full dilation of cervix to delivery of infant
Stage 3Stage 3Begins at delivery of infantBegins at delivery of infantEnds when placenta has been expelled and uterus has Ends when placenta has been expelled and uterus has contractedcontracted
Signs and Symptoms ofSigns and Symptoms ofImminent DeliveryImminent Delivery
Prepare for delivery if:Prepare for delivery if:Regular contractions lasting 45Regular contractions lasting 45--60 sec at 160 sec at 1--2 min 2 min intervalsintervalsUrge to bear down or sensation of bowel movementUrge to bear down or sensation of bowel movementLarge amount of bloody showLarge amount of bloody showCrowning occursCrowning occursMother believes delivery is imminentMother believes delivery is imminent
Signs and Symptoms ofSigns and Symptoms ofImminent DeliveryImminent Delivery
Do not delay or restrain delivery except for cord Do not delay or restrain delivery except for cord presentationpresentation
If complications are anticipated or abnormal delivery If complications are anticipated or abnormal delivery occurs, medical direction may recommend expedited occurs, medical direction may recommend expedited transport to a medical facilitytransport to a medical facility
Assisting with DeliveryAssisting with DeliveryAssist in natural events of childbirthAssist in natural events of childbirth
Responsibilities of EMS crew:Responsibilities of EMS crew:Prevent uncontrolled deliveryPrevent uncontrolled deliveryProtect infant from cold stress after birthProtect infant from cold stress after birth
Full term gestation?Full term gestation?Clear amniotic fluid?Clear amniotic fluid?Is baby breathing or crying?Is baby breathing or crying?Does the baby have good muscle tone?Does the baby have good muscle tone?If yes to all four questions If yes to all four questions
Need to resuscitate is unlikelyNeed to resuscitate is unlikely
Often primigravida experiencing strong, frequent Often primigravida experiencing strong, frequent contractions for long periodcontractions for long period
Cephalopelvic Disproportion Cephalopelvic Disproportion Prehospital carePrehospital care
Maternal oxygen administrationMaternal oxygen administrationIV access for fluid resuscitation if neededIV access for fluid resuscitation if neededRapid transport to receiving hospitalRapid transport to receiving hospital
Elevate motherElevate mother’’s hipss hipsMaternal oxygenMaternal oxygenHave mother pant with contractionsHave mother pant with contractionsApply moist, sterile dressing to cordApply moist, sterile dressing to cordGently push infant back into vaginaGently push infant back into vagina
•• Elevate presenting partElevate presenting part•• Maintain during transportMaintain during transport
Recognition of potential complicationsRecognition of potential complicationsMaternal support and reassuranceMaternal support and reassuranceRapid transport for definitive careRapid transport for definitive care
Premature Birth Premature Birth Birth at <37 weeks of gestationBirth at <37 weeks of gestation
Care of premature infantCare of premature infantKeep warmKeep warmSuction mouth and nares oftenSuction mouth and nares oftenMonitor cord for oozingMonitor cord for oozingAdminister oxygenAdminister oxygen
•• Monitor for need to assist ventilationsMonitor for need to assist ventilationsGently transportGently transport
Deliver first twin as normal birthDeliver first twin as normal birthCut and clamp cordCut and clamp cordSecond twin delivery within 30Second twin delivery within 30--45 min45 min
•• Medical direction may recommend transportMedical direction may recommend transport
Keep warmKeep warmMonitor for severe postpartum hemorrhageMonitor for severe postpartum hemorrhage
Less than 3 hrs from onset of labor to birthLess than 3 hrs from onset of labor to birth
Overactive uterine contractions and little Overactive uterine contractions and little maternal soft tissue or bony resistancematernal soft tissue or bony resistance
Apply gentle counterpressure to headApply gentle counterpressure to head
Position patient supinePosition patient supinePush fundus up through cervical canal orPush fundus up through cervical canal orCover with moist sterile dressingsCover with moist sterile dressingsRapid transportRapid transportMedical direction may advise use of analgesicsMedical direction may advise use of analgesics
Fetal Membrane Disorders Fetal Membrane Disorders Premature rupture of membranesPremature rupture of membranes
Amniotic sac rupture before laborAmniotic sac rupture before labor““TrickleTrickle”” or sudden gush of fluid from vaginaor sudden gush of fluid from vaginaInfection possible if delivery delayedInfection possible if delivery delayedTransport Transport
Amniotic fluid gains access to maternal circulation:Amniotic fluid gains access to maternal circulation:•• During labor or deliveryDuring labor or delivery•• Immediately after deliveryImmediately after delivery
Signs and symptomsSigns and symptomsSame as for pulmonary embolismSame as for pulmonary embolismHigh mortality High mortality
ManagementManagementAs for pulmonary embolismAs for pulmonary embolism
ConclusionConclusionObstetrical emergencies can develop Obstetrical emergencies can develop
suddenly and become life threatening. The suddenly and become life threatening. The paramedic must be prepared to recognize paramedic must be prepared to recognize