A review to Obst & gynae
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A short review to obstetric and gynecological conditions....
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A review to Obst & gynae
- 1. Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory PRESENTED BY:- Ms. DEEPTI DAMODARAN REVIEW OF
- 2. Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory ANATOMY OF FEMALE REPRODUCTIVE SYSTEM
- 3. Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Anatomy Female reproductive system is divided into: External genitalia (vulva) Internal genitalia and Accessory reproductive organs
- 4. Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory PHYSIOLOGY (MENSTRUATION CYCLE) • Length of menstrual cycle is 28 day • 14th day – Ovulation day PHASES :- • Menstrual phase :- shedding of endometrium with discharge through vagina. Release of FSH and low level of LH, ovarian estrogen secretion begins • Proliferative phase:- endometrium regenrates and thickens in preparation for implantation. Single dominant follicle develops to mature follicle, decrease in FSH level (negative feedback), increase in LH (positive feedback), Ovulation occurs
- 5. Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory • Leutal phase:- begins after ovulation and is a relatively finite time period of about 12 to 14 days under LH secretion , Corpus leuteum is formed from ruptured follicle, release of progestrone and estrogen Progestrone helps preparation of endometrium If fertilization does not Corpus leuteum becomes non functional after 10 to 12 days after ovulation and menstruation returns
- 6. Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory EVENTS FOLLOWING FERTILIZATION Process of fusion of spermatozoon with mature ovum which occurs in Ampulary part of fallopian tube • MORULA: two cell stage 30 hrs after fertilization • BLASTOCYST: It possesses an inner cell mass (ICM), or embryoblast, which subsequently forms the embryo, and an outer layer of cells, or trophoblast, surrounding the inner cell mass and a fluid-filled cavity known as the blastocoele
- 7. Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory • Blastocyst formation begins at day 5 after fertilization • IMPLANTATION: occurs in endometrium between 10-11th day. • TROPHOBLAST: placenta and fetal membrane develop from trophoblast • DECIDUA: endometrium of the pregnant uterus • CHORION: outermost layer of the two fetal membrane • AMNION: inner layer of the fetal membrane
- 8. Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory
- 9. Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory PLACENTA AND FETAL MEMBRANE • Placenta is discoid in shape, with two surfaces Maternal (rough and spongy) Foetal surface (covered by smooth and glistening amnion with umbilical cord attached) Fetal blood flow through the placenta is 400 ml/mt Fetal membrane has two parts Amnion (inner smooth layer) and Chorion (outer thick layer)
- 10. Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory UMBILICAL CORD (Funis) • Wharton’s jelly:- a gelatinous substance within the umbilical cord • There are 2 umbilical arteries (deoxygenated blood) and one umbilical vein (oxygenated blood) • Length: 50cm
- 11. Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory PREGNANCY
- 12. Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Stages of Pregnancy 1st trimester (first 12 weeks) – Fetus is being formed 2nd trimester (13-28 weeks) – Uterus grows rapidly, reaching the umbilicus 3rd trimester (29-40 weeks) – Uterus now reaches the epigastrium
- 13. Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory LEVEL OF FUNDUS AT DIFFERENT WEEKS
- 14. Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory EVENTS IN 1ST TRIMESTER SIGNS • Jacquemier’s / Chadwick’s sign:- dusky hue of vestibule and ant. vaginal wall. (local vascular congestion) • Vaginal / Osiander’s sign:- increased pulsation felt at laterla fornices (8th week) • Cervical / Goodle’s sign:- marked softening of the cervix (6th week) • Piskacek’s sign:- asymmetrical enlargement of uterus in case of lateral implantation • Hegar’s sign:- upper part of uterus is enlarged with growing ovum and lower part is empty (6-10 weeks)
- 15. Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory EVENTS IN 2ND TRIMESTER • Quickening :- feeling of fetal movement by mother (18 week, 2wks early in multiparae) • Chloasma:- pigmentation over forehead and cheek (24th week) • Linea nigra:- linear pigmented zone from symphysis pubis to ensiform cartilage • Striae gravidarum:- (pink and white) • Braxton- Hicks contraction:- irregular, infrequent, spasmodia and painless contraction without effect on dilatation of cervix
- 16. Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory EVENTS IN 3RD TRIMESTER FUNDAL HEIGHT Lightening :- at 38th week engagement of presenting part takes place in the pelvis which decreases the fundal height. 32 weeks:- level of ensiform cartilage 36-38 weeks:- engagement takes place at fundus comes down to 32 week level at 40 wks Head floating: 32 wks Head engaged: 40 weeks
- 17. Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory FETAL SKULL SUTURES:- • SAGITTAL – lies between two parietal bones • CORONAL- run between parietal and frontal bone • FRONTAL – lies between two frontal bones • LAMBDOID- separate the occipital bone and two parietal bones • ENGAGING DIAMETER OF FETUS:- Biparietal or Bitemporal diameter
- 18. Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory FETUS IN UTERO
- 19. Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Types of Presentation Cephalic – Normal, head-first birth Breech-Buttocks or both feet deliver first Face - mentum or chin presenting first Brow - frontal bone or brow line Shoulder – acromian process
- 20. Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory STAGES OF LABOUR FIRST STAGE: onset of labour pain to full dilatation of cervix (12 hrs primi, 6 hrs multi) SECOND STAGE: full dilatation of cervix to expulsion of fetus (2 hrs primi, 30 mts multi) THIRD STAGE: expulsion of fetus to expulsion of placenta and membrane (15 mts)
- 21. Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory MECHANISM OF LABOUR DIAMETER OF ENGAGEMENT: Available transverse diameter ENGAGEMENT DIAMETER OF HEAD: Suboccipito bregmatic (9.5 cm) / Suboccipito frontal (10 cm) D Engagement E S Internal flexion C E Internal rotation of head and simultaneous rotation of shoulder N T Crowning Delivery of head by extension
- 22. Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory D Restitution E S External rotation C E Delivery of shoulder and trunk by lateral flexion N T
- 23. Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Post Delivery Same level as mother Wait for pulsating to stop Clamp and cut umbilical cord Note exact time of birth
- 24. Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Cutting the Umbilical Cord Infant warm Sterile clamps or umbilical tape 1st clamp 10 inches 2nd clamp 7 inches Cut between clamps
- 25. Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory SEPARATION OF PLACENTA Methods of separation SCHULTZE :- central separation MATHEW-DUNCAN :- marginal separation
- 26. Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Care of the Newly Born
- 27. Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Care of the Newly Born
- 28. Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Assessment—Newly Born Breathing, heart rate, crying, movement, skin color Pulse greater than 100 bpm Vigorous crying Moving extremities Blue coloration hands and feet ONLY Reassess after 5 minutes
- 29. Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Resuscitation—Newly Born
- 30. Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Respirations Newborn should begin breathing within 30 seconds Provide only small puffs of air if using mouth to mask Rate of 40 to 60 per minute Adequate respirations and a pulse rate greater than 100 per minute – Supplemental oxygen
- 31. Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Heart Rate Heart rate less than 100 beats per minute – Ventilate at a rate of 40 to 60 per minute Heart rate is less than 60 beats per minute – Initiate chest compressions Rate of 120 compressions per minute 3:1 ratio of compressions to respirations 90 compressions and 30 ventilations per minute
- 32. Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory NORMAL PUERPERIUM LOCHIA COLOUR: Lochia rubra- red ( 1- 4 days) Lochia serosa- yellowish / pink/pale (5-9 days) Lochia alba – pale white (10-15 days)
- 33. Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory HEAMORRHAGE IN PREGNANCY ABORTION:- termination of preg before period of viability (28 wks) TYPES:- THREATENED: process of abortion has started but recovery is possible INEVITABLE:- changes have progressed to a stage that recovery is impossible COMPLETE:- product of conception expelled en masse
- 34. Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory INCOMPLETE:- entire product of conception not expelled instead a part is left in uterine cavity MISSED:- when fetus is dead and retained inside uterus for a viable period SEPTIC :- associated with clinical evidence of infection of the uterus CIRCLAGE OPERATION:- Shirodkar and McDonald surgery
- 35. Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory CHILDBIRTH COMPLICATIONS Breech presentation Prolapsed cord Limb presentation Multiple births Premature birth Meconium
- 36. Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Most common abnormal delivery Buttocks first or both legs first Increased risk of prolapsed cord Possible meconium staining Breech Presentation
- 37. Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory BREECH PRESENTATION • Frank breech (buttocks alone) • Complete breech (buttocks ans feet) • Footling breech (both feet) • COMPLICATION:- cord prolapse
- 38. Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Patient Care—Breech Presentation Provide high-concentration oxygen.
- 39. Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Prolapsed Cord Position mother head down and buttocks raised. Provide high-concentration oxygen. Check for pulses and wrap cord. Insert several fingers into vagina to push up on baby’s head. Transport. (cont.)
- 40. Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Prolapsed Cord
- 41. Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Limb Presentation Limb protrudes from vagina Commonly a foot or arm Cannot be delivered in prehospital Rapid transport
- 42. Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Assessment—Limb Presentation Look for crowning Arm or leg Arm and leg together Shoulder and arm
- 43. Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Patient Care—Limb Presentation High-concentration oxygen
- 44. Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Multiple Births More than one baby born during single delivery Twins not considered complication Call for assistance.
- 45. Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Patient Care—Multiple Births
- 46. Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Premature Birth Infant weighs < 5-1/2 lbs (2.5 kgs) Born before 37th week Assessment – Full term vs. premature – Head is larger
- 47. Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Patient Care—Premature Birth
- 48. Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Meconium Results from fetus defecating Sign of fetal or maternal distress Assessment – Amniotic fluid greenish or brownish- yellow – Risk for respiratory problems
- 49. Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Patient Care—Meconium
- 50. Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory EMERGENCIES IN PREGNANCY Ante partum hemorrhage Rupture uterus Ectopic Pregnancy Seizures Miscarriage and Abortion Stillbirths
- 51. Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Placenta Previa Placenta is situated in the lower uterine segment Painless bright red vaginal bleeding TYPES: • Lateral • Marginal • Complete • Incomplete
- 52. Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Abruptio Placentae Premature separation of the placenta Severe abdominal pain Dark red bleeding TYPES:- • Revealed • Concealed • Mixed
- 53. Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Ruptured Uterus As the uterus enlarges throughout pregnancy, the uterine wall becomes extremely thin and is prone to spontaneous or traumatic rupture
- 54. Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Signs and Symptoms Main sign—profuse bleeding Associated abdominal pain Shock Rapid heartbeat
- 55. Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Patient Care—Excessive Bleeding
- 56. Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Ectopic Pregnancy Normal pregnancy—egg divides in the oviduct (fallopian tube) Ectopic pregnancy—egg implanted anywhere outside the uterine cavity Acute abdominal pain Vaginal bleeding Rapid and weak pulse (later sign) Low blood pressure (a very late sign) Features of shock CULLEN’S SIGN : dark bluish discolouration around umbilicus (intraperitoneal bleeding)
- 57. Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Ectopic Pregnancy
- 58. Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Patient Care: Ectopic Pregnancy
- 59. Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Seizures in Pregnancy Pre eclampsia – Hypertension + proteinuria + oedema after 20th week Eclampsia – Preeclampsia superimposed by convulsions or fits Assessment – Elevated BP (above 140/90 mm of Hg) – Excessive weight gain (>1lb a week/ 0.45 kg) – Swelling of face and extremities – Headache
- 60. Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Patient Care—Seizures
- 61. Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Miscarriage and Abortion Termination of pregnancy before 28th week Induced abortion- legal and illegal TYPES: THREATENED (preg can be continued) INEVITABLE (impossible to continue preg) COMPLETE (product of conception expelled en masse) INCOMPLETE ( product of conception expelled in parts) MISSED (dead fetus retained In uterus for long time) SEPTIC (evidence of infection of uterus)
- 62. Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Signs and Symptoms Cramping abdominal pains – Associated with 1st stage of labor Bleeding – Moderate – Severe Discharge – Tissue – Blood
- 63. Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Patient Care—Miscarriage
- 64. Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Stillbirths Baby dies in the womb Continue resuscitation Records
- 65. Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Patient Assessment—Stillbirth Obvious blisters Foul odor Skin or tissue deterioration and discoloration Softened head Cardiac or pulmonary arrest
- 66. Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Patient Care—Stillbirth Obviously dead – No resuscitation Pulmonary or cardiac arrest – Basic life support Imminent death – Prepare to provide life support.
- 67. Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory GYnEcoloGica l EmErGEnciES
- 68. Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory MEDICAL PROBLEMS ASSOCIATED WITH PREGNANCY Anaemia Diabetes Hypertension Heart disease
- 69. Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory ANAEMIA • Hb level is 11gm/100ml or less (acc to WHO) CLASSIFICATION • Mild (b/w 8 to 10 gm%) • Moderate (6.5 to less than 8 gm%) • Severe (< 6.5 gm%) TREATMENT • Daily administration of oral iron ferrous sulphate 200 mg (containing 60 mg of element iron) • Along with 1mg Folic acid • Dietary supplementation
- 70. Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Intravenous and Intramuscular iron therapy • Iron dextran (imferon) which contains 50mg elemental iron in one millimeter
- 71. Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory DIABETES IN PREGNANCY • Glucose travels across the placental membrane via facilitated diffusion • Glucagon is present in the fetal circulation at 8 weeks of gestation • FIRST TRIMESTER : Maternal fasting blood glucose level decreases slightly to approximately 75mg/ 100ml of blood because of the increased glucose supplied to the fetus • SECOND TRIMESTER : Placental hormones (human placental lactogen,progesterone, estrogen) have a diabetogenic effect (producing diabetic-like state). HPL breaks down adipose tissue and release glycerol and fatty acid for the use of primary maternal fuel
- 72. Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory • Third trimester: Delivery of placenta brings about an abrupt drop in the levels of circulating placental hormones, insulinase, & cortisol CRITERIA FOR DIAGNOSIS OF GESTATIONAL DIABETES MELLITUS Criteria for diagnosis of GDM with 100gm of oral glucose GTT: Venous plasma (mg/dl)TIME mg/dl Fasting 1 hour 2 hours 3 hours 95 mg/dl 180 mg/dl 155 mg/dl 140 mg/dl
- 73. Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory EFFECT OF DIABETES MOTHER • Abortion • Preterm labour • Pre-eclampsia • Polyhydramnios • Maternal distress • Diabetic retinopathy • KETOACIDOSIS FETUS • Fetal macrosomia • Congenital malformation • Birth trauma and perineal asphyxia • Hyperbilirubinemia
- 74. Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory HYPERTENSION Pre-eclampsia • A pregnancy-induced hypertension • ≥ 20 weeks gestation • Previously normotensive • ≥140/90 mmHg on at least two occasions • + proteinuria ≥ 0.3g in 24h • ± oedema
- 75. Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory Complications (fetal) • IUGR • Oligohydramnios • Placental infarcts • Placental abruption • Uteroplacental insufficiency • Prematurity • PPH
- 76. Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory ECLAMPSIA • Pre eclampsia superimposed by convulsions is called eclampsia • Magnesium sulphate given IV by infusion pump to prevent or limit seizure • Antihypertensive: methyldopa, hydralazine • Monitor FHR
- 77. Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory HEarT DiSEaSE in PrEGnancY • 50% have origin from rheumatic fever, congenital and mitral valve disorder • Oxygen consumption increased 10% to 20%related to growing fetus • Plasma level and blood volume increase MANAGEMENT:- Give semi fowlers position Assisted birth / Cesarean delivery Monitor heart rate Monitor fetus for IUGR, preterm birth and hypoxia
- 78. Limmer et al., Emergency Care, 11th Edition © 2009 by Pearson Education, Inc., Upper Saddle River, NJ DOT Directory POST PARTUM HAEMORRHAGE • Bleeding in excess of 500 ml following delivery is called PPH TYPES:- • Primary PPH - occurs in the third stage of labour. It is defined as a loss of blood from the genital tract within the first 24 hours after birth. • Secondary PPH - occurs 24h-12 weeks after birth (end of puerperium).
Hinweis der Redaktion
- Blood from the fetus is sent through blood vessels in the umbilical cord to the placenta where the blood picks up nourishment from the mother, then returns through the umbilical cord to the fetus’ body. The fetus is enclosed and protected within a thin, membranous “bag of waters” known as the amniotic sac.
- Breech delivery is considered an abnormal delivery and could potentially present complications.
- The first stage of labor is also called the dilation period. Picture the uterus as a long-neck bottle. In order to expel the contents, the neck of the bottle must be stretched to the size of a wide-mouth jar. Before the cervix can fully dilate, the long neck of the cervix must be shortened and thinned (this process is called effacement) to the wide-mouth-jar shape.
- The vigor of an infant should be assessed as soon as he is born. If you arrive after the birth, it is still your responsibility to make the assessments based on your first observations. Remember, however, that care for the infant and the mother should not be delayed. The assessment is meant to take place while these other activities are being performed.
- Your EMS system may call for a general or a specific evaluation protocol. A general evaluation usually calls for noting ease of breathing, the heart rate, crying, movement, and skin color. A normal newborn should have a pulse greater than 100/min, be breathing easily, crying (vigorous crying is a good sign), moving his extremities (the more active, the better), and show blue coloration at the hands and feet only. Five minutes later, these signs should still be apparent, with breathing becoming more relaxed. The blue coloration may or may not disappear, but it should not spread to other parts of the body.
- Use a bulb syringe, suctioning the mouth first and then the nostrils. Squeeze the bulb before inserting the syringe into the baby’s mouth. Release the bulb to create suction. It may be necessary to use a sterile gauze pad to clear mucus and blood from around the baby’s nose and mouth.
- Provide only small puffs of air if using mouth to mask, and small squeezes on the bag if using an infant-size bag-valve-mask device. Reassess the infant’s respiratory efforts after 30 seconds. If there is no change in the effort of breathing, continue with ventilations and reassessment. Oxygen is best delivered at 10 to 15 liters per minute using oxygen tubing placed close to, but not directly into, the infant’s face.
- The third stage of labor is the delivery of the placenta with its umbilical cord section, membranes of the amniotic sac, and some of the tissues lining the uterus. Although the process may take 30 minutes or longer, avoid the urge to put pressure on the abdomen over the uterus to hasten delivery of the placenta. If mother and baby are doing well, and there are no respiratory problems or significant uncontrolled bleeding, transportation to the hospital can be delayed up to 20 minutes while awaiting delivery of the placenta.
- Place a sanitary napkin over the mother’s vaginal opening. Do not place anything in the vagina. Have the mother lower her legs and keep them together. Tell her that she does not have to “squeeze” her legs together. Elevate her feet. Feel the mother’s abdomen until you note a “grapefruit-sized” object. This is her uterus. Rub this area lightly with a circular motion. It should contract and become firm, and bleeding should diminish. The mother may want to nurse the baby. This will aid in the contraction of the uterus.
- After the amniotic sac ruptures, the umbilical cord, rather than the head, may be the first part presenting at the vaginal opening. This is called prolapsed cord. Position the mother with her head down and buttocks raised with a blanket or pillow, using gravity to lessen pressure on the birth canal. Provide the mother with a high concentration of oxygen by way of a nonrebreather mask to increase the concentration carried over to the infant. The cord must be kept warm. Keeping mother, child, and EMT as a unit, transport immediately to a medical facility. Be prepared to stay in this position until you reach the hospital.
- Limb presentation occurs when a limb of an infant protrudes from the vagina. The presenting limb is commonly a foot when the baby is in the breech position. Limb presentations cannot be delivered in the prehospital setting. Rapid transport is essential to survival.
- When checking for crowning, you may see an arm, a single leg, or an arm and leg together, or a shoulder and an arm. If one or more limbs are present, there is often a prolapsed umbilical cord as well.
- If there is a prolapsed cord, follow the same procedures as you would for any delivery involving a prolapsed cord. Remember, you have to keep pushing up on the baby until relieved by a physician. The baby must be kept off of the cord if he is to survive. For a limb presentation, do not try to pull on the limb or replace the limb into the vagina. Do not place your gloved hand into the vagina, unless there is a prolapsed cord.
- When more than one baby is born during a single delivery, it is called a multiple birth. A multiple birth, usually twins, is not considered a complication, provided that the deliveries are normal. Twins are generally delivered in the same manner as a single delivery, one birth following the other. However, if a multiple birth is encountered, you should have enough personnel and equipment to be prepared for multiple resuscitations. Call for assistance if needed. When delivering twins, identify the infants as to order of birth (one and two, or A and B).
- Since you probably will not be able to weigh the baby, make a determination as to whether the baby is full-term or premature based on the mother’s information and the baby’s appearance. By comparison with a normal full-term baby, the head of a premature infant is much larger in proportion to the small, thin, red body.
- Premature infants are at great risk of developing hypothermia. Once breathing, the baby should be dried and wrapped snugly in a warm blanket. Continue to suction fluids from the nose and mouth using a rubber bulb syringe. Keep checking to see if additional suctioning is required. Examine the cut end of the cord carefully. If there is any sign of bleeding, even the slightest, apply another clamp or tie closer to the baby’s body. The desired temperature is between 90°F and 100°F. Use the ambulance heater to warm the patient compartment prior to transport. In the summer months, the air conditioning should be turned off and all compartment windows should be closed or adjusted to keep the desired temperature.
- To reduce the risk of aspiration, do not stimulate the infant before suctioning the oropharynx. Suction the mouth and then the nose. Provide artificial ventilations and/or chest compression as indicated by effort of breathing and heart rate.
- Either placenta previa or abruptio placentae may occur in the third trimester. Both are potentially life-threatening to the mother and fetus.
- Either placenta previa or abruptio placentae may occur in the third trimester. Both are potentially life-threatening to the mother and fetus.
- Main sign is usually profuse bleeding from the vagina. Mother may or may not experience associated abdominal pain. During initial assessment, look for signs of shock. Obtain baseline vital signs. A rapid heartbeat may indicate significant blood loss.
- If signs of shock exist, treat with high-concentration oxygen and rapid transportation. Place a sanitary napkin over the vaginal opening. Note the time of napkin placement. DO NOT PLACE ANYTHING IN THE VAGINA. Replace pads as they become soaked, but save all pads for use in evaluating blood loss. Save all tissue that is passed.
- Ensure and maintain an open airway. Administer high-concentration oxygen by nonrebreather mask. Transport the patient positioned on her left side. Handle her gently at all times. Rough handling may induce more seizures. Keep her warm, but do not overheat. Have suction ready. Have a delivery kit ready.
- For a number of reasons, the fetus and placenta may deliver before the 28th week of pregnancy—generally before the baby can live on his own. This occurrence is an abortion. When it happens on its own, it is called a spontaneous abortion, more commonly known as a miscarriage.
- Women having a miscarriage that requires them to seek emergency care generally have the following signs and symptoms: Ask the patient about the starting date of her last menstrual period. If it has been more than 24 weeks, be prepared with a delivery pack. Premature infants may survive if they receive rapid neonatal intensive care.
- Treatment should be based on signs and symptoms. Provide emotional support to the mother. Emotional support is very important. When speaking to the patient, her family, or where bystanders may hear you, ALWAYS use the term miscarriage instead of spontaneous abortion. Most people associate the word abortion with an induced abortion, not a miscarriage. It is essential to talk with the patient to gain her confidence and to allow you to provide emotional support.
- Stillborn babies who have obviously been dead for some time before birth are not to receive resuscitation. Any other babies who are born in pulmonary or cardiac arrest are to receive basic life support measures. When the baby is alive but respiratory or cardiac arrest appears to be imminent, prepare to provide life support.
- Vaginal bleeding that is not a result of direct trauma or a woman’s normal menstrual cycle may indicate a serious gynecological emergency. Situations where a sexual assault has occurred are always a challenge to the EMT. Care of the patient must include both medical and psychological considerations. In addition, law enforcement agencies are also frequently involved.