First, boil water… Obstetrics for Paramedics

1. First, boil water…Obstetrics for Paramedics Rebecca Dunsmoor-Su, MD

2. Outline • The basics (anatomy, terminology) • Normal pregnancy • Abnormal pregnancy • First trimester • Later • Trauma • Normal labor & delivery • Abnormal labor & delivery • What do you do with the baby?

4. Anatomy

5. Anatomy

6. Terminology • Gs and Ps • LMP • EDC • Primip • Multip • Precip • Antenatal • Antepartum

7. Terminology • Gravidity: Number of times pregnant • Parity: Number of deliveries (twins only counts as one) • Usually expressed as G3P2 • Can also be G3P2012 • P(term, preterm, abortions, living kids)

8. Terminology • LMP: Last menstrual period. Pregnancies are dated from the first day of the LMP • EDC: Estimated date of confinement (EDD: estimated date of delivery) • For a rough estimate: Add 7 days to 1st day of LMP, then add 9 months. (Nagele rule)

9. Terminology • Primip: Primipara. Technically, someone who has had one delivery. Practically, used interchangably with primagravida • Multip: Multipara. Techinically, someone who has delivered more than one baby. Practically, anyone who has delivered a baby.

10. Terminology • Precip: Precipitous delivery. One that happens way too fast - and what you are most likely to see in your ambulance! Technically, delivery after less than 3 hours of labor. • Antenatal, Antepartum: Before delivery

11. Normal pregnancy • Heartbeat visible on US: 5-6 weeks • Heartbeat audible with Doppler: 12 weeks • Heartbeat audible with stethoscope: 20 weeks • Viability: 24 weeks • Term: 40 weeks (>37 weeks)

12. Normal pregnancy • Uterus palpable above pubic bone ~12 weeks • Uterus at umbilicus at 20 weeks • After 20 weeks, cm measured from symphysis to fundus is approx = to GA

13. Fundal height Fetal HR 120-150

14. Physiologic changes • Respiratory: Progesterone increases respiratory drive, therefore increased rate, slightly lower PCO2 • Cardiovascular: Drop in SVR, drop in BP, increase in pulse. Increased blood volume. • Renal: Progesterone relaxes ureter, increasing risk of pyelonephritis • GI: Progesterone relaxes sphincters, slows peristalisis: increasing GERD

15. Physiologic changes • Hematologic: Increased blood volume, but less increase in RBCs leads to relative anemia • MSK: Progesterone loosens joints, growing uterus changes center of gravity

16. Beware supine hypotension! ALWAYS: Left lateral tilt

17. Evaluation of a pregnant patient • ABC’s. • Mom is first priority, but always remember that you have TWO patients. • Primary survey is the same.

18. Evaluation of a pregnant patient • Secondary survey: • Include palpation of uterine fundus • Listen for fetal heartbeat • Vaginal bleeding or leaking of fluid? • Anything protruding from vagina? • Tender abdomen?

19. Gs and Ps LMP / EDC Bleeding? Leaking fluid? Contracting? Baby moving? Medical Comorbidities? Any prenatal care? Headache? Blurry vision? RUQ pain? Seizures? Trauma? Fall? Any problems with placenta? Obstetric HPI

20. Obstetric History • POBHx: • Any C-sections? • Any surgery on uterus? • Any problems with past pregnancies?

21. Physical exam • Pulmonary • Abdominal • Uterus • Fetus • Perineum • DO NOT do an internal vaginal exam!

22. Abnormal pregnancy • First Trimester (0-14 weeks) • Bleeding: • Up to 20% of pregnancies end in miscarriage • Vaginal bleeding in the first trimester should ALWAYS make you think of ectopic pregnancy • If patient appears sick, consider septic abortion and ask about medications or instrumentation • Inevitable vs. Threatened vs. Incomplete

23. All pregnant women with bleeding and/or abdominal pain have an ectopic until proven otherwise. Bleeding ectopic is a true OB/Gyn emergency and needs to get to an OR Abnormal pregnancyFirst Trimester uterus ectopic

24. Abnormal pregnancyafter 20 weeks • Bleeding: • Placenta previa • Placental abruption • Preterm labor • PPROM • Medical: • Pre-eclampsia • Eclampsia • Diabetes

25. Placenta previa Painless vaginal bleeding Associated with placenta accreta (placenta growing into uterine wall) ANY bleeding is a bad sign, proceed with haste.

26. Placental abruption • Painful vaginal bleeding • Signs: • Bleeding, contractions, abdominal tenderness, pain • Risk factors: • Cocaine, Trauma, HTN, PPROM, Smoking, Multiparity

27. Preterm labor • Technically, labor prior to 37 weeks. Practically, no treatment to stop contractions if >34 weeks. • Difficult diagnosis in the field, since labor implies cervical change. • Err on the side of caution and presume any abdominal or back pain is contractions. • Many causes

28. PPROM Preterm Premature Rupture of Membranes • Sometimes hard to diagnose • Often caused by infection • Associated with increased risk of abruption, cord prolapse, cerebral palsy (when accompanied by infection)

29. Pre-eclampsia • Blood pressure >140/90 • Proteinuria >1+ (300mg/24h) • Symptoms: • Headache • Blurry vision • RUQ pain • Edema • Signs: • Hyperreflexia • Pulmonary edema • Oliguria

30. Associated with: Seizures (eclampsia) Stroke HELLP: Hemolysis Elevated Liver enzymes Low Platelets Abruption Key treatment: Magnesium sulfate and/or delivery Pre-eclampsia

31. Diabetes • Placenta makes a hormone, HPL, that creates insulin resistance. • Pre-existing diabetes is worsened by pregnancy • Some women develop gestational diabetes (like Type 2) and may be on insulin (so think about hypoglycemia) • DKA can develop more quickly and at lower blood sugar than in non-pregnant women

32. Trauma • Number one cause of non-obstetric maternal death • Treat mom first • Volume, volume, volume (be careful) • Remember left lateral tilt • Fetal survival drops dramatically 15 minutes after a maternal arrest, but 90% will survive if C-section done prior to 15 minutes. • All but the most minor trauma over 24 weeks will have at least 4 hours of uterine monitoring to evaluate for abruption. (After 20 weeks - 5 months - ideal to transport everyone for evaluation)

33. Normal labor and delivery What do we mean by labor? • 3 stages of labor • Stage 1: 0-10 cm dilation • (Active phase after 3-4cm) • Stage 2: 10cm to delivery • Stage 3: delivery of baby to delivery of placenta

34. Delivery • Don’t panic. • Control the infant head • Support maternal perineum • Once head is out, sweep for nuchal cord • Gentle downward traction, then gentle upward traction • Support fetal body

37. Nuchal cord

38. Third stage • Signs of placental separation: • Gush of blood • Lengthening of cord • Avoid heavy traction on the cord • Monitor for increased bleeding • Fundal massage • Pitocin (20 units in 1 litre) - can start this as soon as the baby is out.

39. Prolapsed cord Cephalopelvic disproportion Shoulder dystocia Breech presentation Limb presentation Meconium Uterine rupture Post-partum hemorrhage Uterine inversion Amniotic fluid embolus Pulmonary embolus Abnormal labor and delivery

40. Prolapsed Cord • OB emergency: essentially cuts off all oxygen to fetus • Cesarean delivery STAT • In field: hand in vagina, elevate fetal head off the cord. • Elevate hips: knee to chest or Trendeleberg

41. Cephalopelvic disproportion • Prolonged labor • Minimal expected cervical change is ~1cm/hr in active phase. • Slower rate can indicate malposition, large baby, inadequate contractions

42. Shoulder dystocia • Anterior shoulder stuck behind pubic symphysis • Signs: • Shoulder does not deliver easily with next contraction • Head retracts “turtle sign” • McRoberts maneuver: Knees to ears! • This is like a code: document, document, document

43. Abnormal presentation Breech Footling breech Limb presentation • Risks: • Head entrapment • Cord prolapse

44. Breech delivery Allow progress of labor and pushing to deliver baby past hips Support the infant body, and wrap it in a towel Grasp infant at hips, with thumbs on sacral alae Pull gently down until you see the scapula Reach up and sweep down each arm Put fingers on maxillae to flex head and/or provide space for baby to breathe

45. Meconium • Theory is that it indicates baby under stress • Previously all babies with meconium had deep suction prior to delivery of shoulders. • Now, only those with poor respiratory effort or sats should be intubated and suctioned. • Suction mouth and nose on perineum and be prepared.

46. Uterine rupture • Signs: • Vaginal bleeding • Loss of fetal station • Abdominal pain • Acute abdomen • Fetal distress • Maternal shock • 0.5-1% risk in women with one prior C-section • 5-50% risk of fetal death • Risk of maternal hemorrhage

47. Post-partum hemorrhage • >500cc after vaginal delivery • Can be a sign of uterine atony, retained placenta, placenta acreta • Rx: • Fundal massage • Empty bladder • Pitocin (20-40units in 1L NS) • Misoprostol 600-800mcg per rectum • Hemabate / methergine

48. Uterine Inversion Try to gently push it back in. Do not remove placenta! Proceed with haste to an OB

49. Emboli Amniotic fluid or blood clot Present as sudden hypoxia, dyspnea, cardiovascular compromise Treat as any patient in shock, pulmonary arrest or with severe hypotension

50. What do I do with the baby? Airway & Breathing Tone & Reflexes Circulation & Color Dry the baby and keep her warm: skin to skin is best