3. Topics
The Prenatal Period
General Assessment
General Management
Complications of Pregnancy
Abnormal Delivery Situations
Other Delivery Complications
Maternal Complications of Labor and
Delivery
4. Introduction
Childbirth occurs daily, usually requiring
only the most basic assistance
Childbirth complications include:
– Preterm labor, multiple births, abnormal
presentations, bleeding, or distressed neonates
Complications of pregnancy are uncommon
– Hypertension, eclampsia, diabetes,
cardiovascular, and trauma are causes
6. The Prenatal Period
The prenatal period is the time from
conception until delivery of the fetus.
Significant physiological changes occur in
the mother.
– The result of fetal development
7. Anatomy and Physiology of
the Obstetric Patient
Ovulation
Fertilization
– Normally occurs
in the fallopian
tube
– Blastocyst forms
Implants in the
thickened uterine
lining
8. Anatomy and Physiology of the
Obstetric Patient
Placenta
– Organ of pregnancy
– Function
Exchanges heat
Exchanges oxygen for carbon dioxide
Delivers nutrients
Removes wastes
– Endocrine function
9. Anatomy and Physiology of the
Obstetric Patient
Uterus
– Normal capacity 10 mL
– By term
2 pounds
5 Liters
Contains 1/6 of Mom’s blood volume
10. Anatomy and Physiology of the
Obstetric Patient
Umbilical cord
– Two arteries
and one vein
Vein transports
oxygen rich
blood
Amniotic sac
– “Bag of waters”
– Contains
amniotic fluid
11. Physiologic Changes
of Pregnancy
Reproductive System
– Uterus increases in size
– Vascular system
– Formation of mucous
plug in cervix
– Estrogen causes vaginal
mucosa to thicken
– Breast enlargement
12. Physiologic Changes
of Pregnancy
Respiratory System
– Progesterone causes a decrease in airway
resistance
Results in a 20 percent increase in oxygen
consumption and a 40 percent increase in tidal volume
– Slight increase in respiratory rate
34. General Assessment of
the Obstetric Patient
General Information
– Mother’s gravidity and parity
– Length of gestation
– Estimated date of confinement (EDC)
– Complications
– Prenatal care
– State of health
35. General Assessment of
the Obstetric Patient
Preexisting or Aggravated Conditions
– Diabetes
Diabetics become unstable during pregnancy
Larger baby – shoulder dystocia
Gestational diabetes
Must be treated with insulin
Oral meds cross placenta
– Heart Disease
Congestive heart failure may develop
36. General Assessment of
the Obstetric Patient
Preexisting or Aggravated Conditions (cont.)
– Hypertension
Common medications may not be used
Pre-eclampsia may develop
– Seizure Disorders
Increased seizures
– Neuromuscular Disorders
Patients may have remission of symptoms during
pregnancy
37. General Assessment of
the Obstetric Patient
Pain
– Determine when the pain started
Sudden onset or slow
– Duration, location, and radiation
Vaginal Bleeding
– Gain information about the color, amount, and
duration
Assess number of sanitary pads used
– Transport any tissue or clots
38. General Assessment of
the Obstetric Patient
Active Labor
– Need to push?
– Need to have BM?
– Membranes ruptured?
What did it look like?
39. General Assessment of
the Obstetric Patient
Physical Examination (cont.)
– Vital signs (lying on left side)
– Evaluate:
vaginal discharge
progression of labor
prolapsed cord
crowning
– Never perform an internal vaginal exam in
the field.
41. General Management of
the Obstetric Patient
Always remember that you are caring for
two patients, the mother and the fetus.
Maintain the airway, breathing, and
circulation.
– Oxygen administration, IV access
Patient positioning
Transport considerations
43. Complications of Pregnancy
Trauma
– Pregnant patients are more susceptible to life-
threatening injury
Increased vascularity of the gravid uterus
Transport all trauma patients at 20 weeks or more
gestation
– Anticipate the development of shock
Overt signs of shock are late
– Direct abdominal trauma
Premature separation of the placenta from the uterine
wall, premature labor, abortion, uterine rupture, and
possibly fetal death
44. Trauma Management
Immobilize as necessary
Administer high-flow oxygen
Initiate two large-bore IVs per protocol
LSB tilted to the left to minimize supine
hypotension
Reassess patient
Monitor the fetus
45. Medical Conditions
Abdominal pain is a common complaint
– Appendicitis or cholecystitis
Displacement of abdominal organs complicates
assessment
Symptoms of acute cholecystitis may differ from those
in nonpregnant patients
Any pregnant patient with abdominal pain
should be evaluated by a physician.
46. Bleeding In Pregnancy
Causes
– Abortion
– Ectopic Pregnancy
– Placenta Previa
– Abruptio Placentae
Vaginal bleeding is associated with
potential fetal loss
47. Abortion
Termination of pregnancy before the 20th
week of gestation
Assessment
– Cramping, abdominal pain, backache, and
vaginal bleeding
– Passage of clots and tissue
Management
– Treat for shock
– Provide emotional support
48. Ectopic Pregnancy
Abnormal implantation of
the fertilized egg outside
of the uterus
– Most commonly in the
fallopian tube
– Accounts for approximately
10 percent of maternal
mortality
49. Ectopic Pregnancy
Assessment
– Presence of abdominal pain
– Woman often reports that she missed a period
– The abdomen becomes rigid and the pain
intensifies
– Signs of shock
Management
– Transport this patient immediately
– Treat for shock
Consider use of PASG
50. Placenta Previa
Abnormal implantation of the placenta on
the lower half of the uterine wall
Contractions pull placenta from uterine wall
– Results in bleeding
52. Placenta Previa
Assessment
– Usually a multigravida in her third trimester of
pregnancy
May have history of placenta previa
– Recent episode of sexual intercourse or vaginal
examination
– Painless bright red vaginal bleeding
Management
– Treat for shock
– Transport to appropriate facility
55. Abruptio Placentae
Predisposing factors
– Multiparity, maternal hypertension, trauma,
cocaine use, increasing maternal age, and
history of abruption in previous pregnancy
20 to 30% fetal mortality
– Increases to 100% when majority of the
placenta has separated
56. Abruptio Placentae
Assessment
– Varies depending on the extent and character
Partial
Marginal is characterized by vaginal bleeding but no increase in
pain
Central is characterized by sudden sharp, tearing pain and
development of a stiff, board-like abdomen
Complete
Massive vaginal bleeding and profound maternal hypotension
57. Abruptio Placentae
Management
– Immediate intervention to maintain maternal
oxygenation and perfusion
Oxygenation and intravenous fluid therapy
– Left-lateral recumbent position
– Transport to appropriate facility
59. Hypertensive Disorders
of Pregnancy
Pre-eclampsia and Eclampsia
– Mild or Severe
– Increase in systolic blood pressure by 30 mmHg
and/or a diastolic increase of 15 mmHg
Two or more occasions
– Most commonly seen in the last 10 weeks of
gestation, during labor, or in the first 48 hours
postpartum
60. Hypertensive Disorders
of Pregnancy
Preeclampsia and Eclampsia (cont.)
– Mild pre-eclampsia
Hypertension, edema, and protein in the urine
– Severe pre-eclampsia
Maternal blood pressure reaches 160/110 or higher,
generalized edema, large amounts of protein in urine
Other symptoms include headache, visual
disturbances, hyperactive reflexes, and the
development of pulmonary edema
62. Hypertensive Disorders
of Pregnancy
Chronic hypertension
– Blood pressure is 140/90 before pregnancy or
prior to the 20th week of gestation
Chronic hypertension superimposed with
pre-eclampsia
Transient hypertension
– A temporary rise in blood pressure which occurs
during labor
64. Hypertensive Disorders
of Pregnancy
Management
– Hypertension
Closely monitor mother and fetus
– Pre-eclampsia
Keep the patient calm
Dim the lights
Left lateral positioning
IV access
Administration of magnesium sulfate
– Eclampsia
Administer oxygen
Bolus dose of magnesium sulfate
Diazepam as indicated
66. Assessment
– History of supine positioning
– Patient may complain of dizziness
– Question any recent hemorrhage or fluid loss
Management
– Place the patient in the left lateral recumbent
position or elevate her right hip
– Monitor fetal heart tones and maternal vital
signs
– Transport left-lateral recumbancy
Supine Hypotensive Syndrome
67. Gestational Diabetes
Hormonal influences cause an increase in
insulin production
– Initially, an increased tissue response to insulin
– During the last 20 weeks placental hormones
cause an increased resistance to insulin and
decreased glucose metabolism
Management requires good prenatal care
69. Gestational Diabetes
Management
– If blood glucose less than 60
Obtain blood sample
Administer D50%
Consider oral glucose depending on patient LOC
– If blood glucose greater than 200
Obtain blood sample
Give fluid bolus of 1-2 liters
Medical control may order insulin if delayed or long
transport
70. Braxton-Hicks Contractions
False labor
Virtually impossible to distinguish false labor
from true labor in the field
Transport patient for evaluation
– Requires examination of the cervix
WHICH WE DO NOT DO
72. Preterm Labor
Assessment
– Determine the approximate gestational age of
the fetus
<38 weeks is pre-term
– Obtain a brief obstetrical history
Ruptured membranes
Need to push or move bowels
Note the intensity and length of the contractions and
contraction interval
– Other common complaints
73. Preterm Labor
Management
– Preterm labor should be stopped if possible
Tocolysis
Narcotic or barbiturate administration and rest
Fluid bolus administration
Magnesium sulfate or beta agonist administration
– Tocolysis in the field is limited to sedation and
hydration
75. Management of
a Patient in Labor
Transport the patient in labor unless delivery
is imminent
Considerations
– Patient’s number of previous pregnancies
– Length of labor during the previous pregnancies
– Frequency of contractions
– Maternal urge to push
– Presence of crowning
76. Management of
a Patient in Labor
Factors indicating rapid transport despite
imminent delivery
– Prolonged rupture of membranes (> 24 hours)
– Abnormal presentation, such as breech or
transverse
– Prolapsed cord or fetal distress
– Multiple fetuses
77. Field Delivery
Set up delivery area
Give oxygen to
mother and start IV-
NS TKO
Drape mother with
toweling from OB kit
Monitor fetal heart
rate
As head crowns,
apply gentle
pressure
Suction the mouth
and then the nose
Clamp and cut the
cord
Dry the infant and
keep it warm
Deliver the placenta
and save for
transport with the
mother
81. Neonatal Resuscitation
Factors that contribute to the need for
resuscitation
– Prematurity, pregnancy and delivery
complications, maternal health problems, or
inadequate prenatal care
Tactile stimulation
– If respiratory effort insufficient, assist ventilations
with BVM and oxygen
Reassess after 15-30 seconds
Continue as necessary with ventilations
82. Neonatal Resuscitation
Assess heart rate
– Use a stethoscope to auscultate the apical pulse
If the pulse is 100 or greater with spontaneous
respirations, continue your assessment
If less than 100 - VENTILATE
If less than 60 -
COMPRESSIONS
83. Neonatal Resuscitation
Transport to appropriate facility
Establish intravenous access
– Umbilical vein
– Peripheral vein
– Intraosseous
– Endotracheal drug administration for cardiac
drugs
Maintain warmth, support ventilations,
oxygenation, and circulation enroute
87. Breech Presentation
Either the buttocks or both
feet present first
– Increased risk for delivery
trauma to the mother
– Increased potential for cord
prolapse, cord
compression, or anoxic
insult for the infant
88.
89. Breech Presentation
Management
– Position the mother with her buttocks at the
edge of a firm bed
Flex legs
– Deliver the infants legs and support
– As the head passes the pubis, apply gentle
upward traction until the mouth appears over the
perineum
90. Breech Presentation
If head does not
deliver:
– Insert gloved hand
with “V” fingers to
move vaginal wall
from airway
91. Breech Presentation
Shoulder delivery
– Gently rotate in an anterior-posterior position
– Guide infants body upward
Deliver posterior shoulder
– Guide infant downward to deliver anterior
shoulder
92. Prolapsed Cord
Occurs when the umbilical cord precedes
the fetal presenting part
– Cord is compressed between the fetus and the
bony pelvis
Impedes circulation
Predisposing factors
– Prematurity
– Multiple births
– Premature rupture of the membranes
94. Limb Presentation
Baby is in a transverse lie across the uterus
– Arm or leg is presenting part
Predisposing factors
– Preterm birth and multiple gestation
Management
– Under no circumstance should you attempt a
field delivery
– Assist the mother into a knee-chest position
– Administer oxygen and transport immediately
95. Other Abnormal Presentations
Occiput-posterior positioning
– Passage through the pelvis is delayed
Most frequent with primigravidas
– Vaginal delivery is impossible in these cases
Management
– Early recognition
– Reassure mother
– Transport with oxygen administration
99. Multiple Births
Multiple births should also be suspected if
the mother’s abdomen remains large after
delivery of one baby and labor continues
Management
– Normal delivery guidelines
Additional personnel necessary
– Low birth weight increases chance of
hypothermia
Maintain warmth
100. Cephalopelvic Disproportion
Infant’s head is too big to pass through
pelvis easily
– If not recognized, can cause uterine rupture
Causes include oversized fetus,
hydrocephalus, conjoined twins, or fetal
tumors
Management
– Give oxygen to mother and start IV
– Rapid transport
101. Precipitous Delivery
Delivery occurs in less than 3 hours of labor
– Usually in patients in grand multipara
– Complications
Fetal trauma, tearing of cord, or maternal lacerations
Management
– Be ready for rapid delivery and attempt to
control the head
– Keep the baby warm
102. Shoulder Dystocia
Infant’s shoulders are
larger than its head
– Most frequently with
diabetic and obese
mothers and in post-term
pregnancies
During delivery, head
retracts back into
perineum
– Turtle sign
103. Shoulder Dystocia
Management
– Do not pull on the infant’s head
– McRobert’s Manuever
Flex legs, drop mother’s buttocks off bed
Apply pressure to immediately above symphysis pubis
– If delivery delayed, transport immediately
105. Meconium Staining
Fetus passes feces into the amniotic fluid
– Indicative of a fetal hypoxic incident
– Risk of aspiration
Management
– Suction the mouth and nose on the perineum
– If staining is light, no further care
– If staining is thick:
Visualize the glottis and suction the hypopharynx and
trachea
Utilize endotracheal tube
110. Postpartum Hemorrhage
Defined as a loss of more than 500 cc of
blood following delivery
– Most common cause is uterine atony
Multigravida
Precipitous deliveries and prolonged labors
– May occur up to 2 weeks post-delivery
111. Postpartum Hemorrhage
Assessment
– Rely on the clinical appearance of the patient
and her vital signs
– Assess number of sanitary pads used
– “Boggy” uterus
– Examine the perineum for evidence of traumatic
injury
112. Postpartum Hemorrhage
Management
– Administer oxygen and begin fundal massage
– Establish IV access
– PASG
– Administration of Pitocin may be indicated
10-20 units in 1 liter of NaCl
Run at 125 cc/hr
May administer 10 units intramuscularly, if necessary
113. Uterine Rupture
Tearing, or rupture, of the uterus
Patient complains of severe abdominal pain
and will often be in shock. Abdomen is often
tender and rigid.
Fetal heart tones are absent
Management
– Treat for shock
– Give high-flow, high-concentration oxygen and
start two large-bore IVs of normal saline
– Transport patient rapidly
114.
115. Uterine Inversion
Uterus turns inside out after delivery and
extends through the cervix
– Blood loss ranges from 800 to 1,800 cc
Management
– Place the patient in a supine position and begin
oxygen administration
– Begin fluid resuscitation
– Make one attempt to replace the uterus
– If unsuccessful, transport immediately with moist
towels covering exposed uterus
116.
117. Pulmonary Embolism
Presents with sudden severe dyspnea and
sharp chest pain
– Tachycardia, tachypnea, jugular vein distention,
and, in severe cases, hypotension
Management
– Administer high-flow, high-concentration oxygen
and support ventilations as needed
– Establish an IV of normal saline
– Transport immediately, monitoring the heart,
vital signs, and oxygen saturation
