4-9 Obstetrics/Gynecology

Signs and symptoms

Mother

• Bloody show.
• Contractions that are short intervals apart and intense.
• Patient has an urge to defecate.
• Patient has a strong urge to push.
• Crowning.
• Sudden onset of intense, sharp and constant pain that does not subside between contractions indicate ruptured uterus.
• Painless vaginal bleeding and symptoms of shock suggests placenta previa.
• Any female of childbearing age with abdominal pain should be suspected of having ectopic pregnancy and transported to the hospital.

Infant

• Greenish or brownish staining of the amniotic fluid.
• Poor response to stimulation.
• Lack of movement.
• Respiratory rate over 60.
• Inadequate breathing.
• Heart rate over 180 or below 100.
• Hypoperfusion, cyanosis.

Treatment

Mother

• Ensure patent airway.
• Provide oxygen because pregnancy increases the demand for oxygen.
• Treat for shock by positioning the patient in Trendelenburg position if bleeding causes hypoperfusion.
• Apply sanitary pads for vaginal bleeding.
• Place patient on her left side or in a sitting position. Avoid the supine position as it will cause a drop in blood pressure.
• If the mother goes into cardiac arrest, begin CPR and don't stop until the baby is surgically delivered.
• Transport patients with miscarriage, because anything that isn't passed through will result in infection.
• Delivering a baby when delivery is imminent.
  • Place patient on her back, with legs bent and spread apart.
  • Suction the nose and the mouth immediately upon delivery of the head.
  • Support the head to prevent explosive delivery.
  • Deliver each shoulder.
  • Support infant with both hands and keep above the level of the vagina.
  • Cut umbilical cord: clamp umbilical cord one at 6 inches and the other at 9 inches from the infant's abdomen.
  • Allow the placenta to deliver and carry it with you to the receiving facility.
  • Dry the infant and wrap in blanket.
  • Allow the baby to suckle on the mother's breast as this helps the uterus to contract.

Infant

• Treat cyanotic infants by blowing oxygen across the infant's face.
• If breathing is inadequate, give PPV at rate of 40-60 per min in addition to oxygen.
• If heart rate drops below 60, begin CPR.
• If umbilical cord presents first, protect it with a sterile dressing moistened with sterile saline solution. Keep pressure off the cord by pushing on any parts of the infant that is presenting. Position patient in a knee-chest or Trendelenburg position.
• If breech birth occurs, support the infant during delivery. When the body is delivered but the head can't, provide an airway to the infant's nose and mouth. Do this by inserting your index and middle fingers in a V shape into the vagina, along the walls, with the infant's nose and mouth between your fingers.
• For limb presentation or shoulder dystocia, position mother in a knee-chest position. Have the mother pant if she has the urge to push.
• If meconium staining is observed, suction the infant's mouth and nose as soon as it presents and before the baby is stimulated to breathe.
• For premature births, provide infant with oxygen by blowing oxygen across the infant's face. Insulate the infant to maintain body temperature. Protect the infant from contact or exhaled breath of others who might transmit infections.
• Transport as fast as possible while stabilizing the patient.

Medical conditions and mechanisms

• Ectopic pregnancy: faulty implantation of the embryo inside the fallopian tube or outside the uterine wall, where it can not support the growing embryo. Eventually, the tissue ruptures, and causes massive internal bleeding.
• Pregnancy lasts for 9 months, or 3 trimesters, at the end of which, labor begins.
• Labor: contraction of the uterine wall to expel the fetus and the placenta.
  • Dilation: first stage of labor, involves the dilation of the cervix. The infant's heat can now progress to the birth canal.
  • Expulsion: second stage of labor. Begins with complete cervical dilation and end with the delivery of the baby. During this stage, the rectum is compressed, which is why the mother feels the urge to defecate.
  • Placental: begins after the delivery of the baby and ends with the expulsion of the placenta.
• Supine hypotensive syndrome: when a pregnant patient is supine, the weight of the uterus and fetus presses on the inferior vena cava. This drops the blood pressure and may lead to inadequate perfusion.
• Breech birth: buttocks or lower extremities present first.
• Placenta Previa: the placenta implants over or near the opening of the cervix. Movement of the infant or dilation of the cervix can cause the placenta to tear off the uterine wall prematurely and produce massive bleeding.
• Abruptio placentae: abnormal separation of the placenta from the uterine wall prior to birth. This causes bleeding and hypoperfusion to the fetus.
• Preeclampsia is where vasospasms cause an increase blood pressure, causes swelling, headaches and visual disturbances. This can become Eclampsia when the patient experiences seizures or coma.

Terms

• Bloody show: vaginal discharge of the cervical mucus plug, which signals the beginning of labor.
• Crowning: appearance of the baby's head.
• Cephalic delivery: normal delivery where the head presents first.
• Obstetric: related to pregnancy and childbirth.
• Prolapsed cord: instead of the head, the umbilical cord is the first part to present.
• Knee-chest position: kneeling and bent forward with face down, chest to knees.
• Limb presentation: either the arm or leg presents first.
• Meconium: bowel movement of the fetus, staining the amniotic fluid to greenish or brownish color. Occurs when the infant is in hypoxic distress.
• APGAR: scoring system that assesses the infant's condition. If total apgar score is 0-3, provide oxygen, ventilate and perform CPR. If 4-6, provide stimulation and oxygen. 7-10 is healthy.
  • Appearance: pink is good (2) , cyanotic is bad (0). Cyanotic only at the extremities is in between (1).
  • Pulse: fast, over 100 is good (2), no pulse is bad (0). Anything in between (1).
  • Grimace: responsive with grimace and makes sounds is good (2), unresponsive is bad (0). Facial grimace only (1).
  • Activity: active movement is good (2), no movement is bad (0). Some flexion (1).
  • Respiration: strong cry is good (2), apnea is bad (0). Weak cry (1).
• Braxton-Hicks contractions: also called false labor. These are painless, short and irregular contractions as early as the 13th week of pregnancy.
• Precipitous delivery: birth with less than 3 hours of labor, which increases risks of trauma.
• Shoulder dystocia: when the baby's shoulders are wider than the head. The head can pass through but the shoulders can't.