Obstetrics, its not all hearts and babies. Emergency obstetric assessment and care

During pregnancy, several changes occur in the maternal body in order to accommodate fetal life.

• Blood volume increases by 45%

• Resting HR increases by 10-15 BPM

• BP decreases by 10-15 mmHg due to increased abdominal pressure on the IVC.

• Respirations increase but become more shallow as there is less room for the thoracic cage to expand during inspiration.

OBS/GYN focused history:

• Is the patient having any dizziness, nausea, or blurred vision?

• Has the patient had regular prenatal appointments/care?

• Is the patient expecting any complications with the pregnancy?

• What is the patient's GTP?

• What is the expected due date?

• Have there been any issues during the pregnancy or any prior ones?

• Is abdominal pain present or are there contractions?

• Has there been any vaginal discharge or bleeding?

• What is the patient's uterine height?

Ectopic(tubal) pregnancy: This occurs when the fertilized ovum implants anywhere outside of the uterine wall. The most common location is in one of the fallopian tubes. Symptoms usually occur early, often within the first 4-8 weeks of pregnancy. Presentation is usually that of sharp, tearing, pain in the lower abdomen; often localized to the affected side. This is why it is important to consider pregnancy a possibility in any female of child bearing age who presents with abdominal pain. Treatment involves maintaining ABCs and supportive care.

Miscarriage/Spontaneous Abortion: This is technically classified as any spontaneous delivery of the fetus before the 20th week of gestation. Surfactant does not develop in the lungs until after the 22nd week, and life is not sustainable outside of the womb prior to the 20th week. Signs and symptoms include cramping, a lot of bleeding, and passing of fetal materials. Treatment involves maintaining ABCs, monitoring vitals, and addressing the emotional needs of the patient.

Abruptio Placenta: This occurs during the 2nd or 3rd trimester, and occurs when there is a sudden partial, or complete, detachment of the placenta from the uterine wall. This presents with severe pain, bight red bleeding, and signs of shock. There may be a history of trauma as a possible causative mechanism. Treatment involves managing ABCs, addressing hypotension conservatively to maintain SBP of 90mmHg, and monitoring for decompensation.

Placenta Previa: Placenta previa occurs when there is a low lying placenta that either partially or completely occludes the cervical opening. This is usually found during routine ultrasound, and caesarian delivery is scheduled. In the prehospital environment we can encounter this if cervical dilation begins to occur, and it presents with painless, bright red, bleeding. Treatment is the same as for abruptio placenta.

Management of newborn post-delivery:

1)Maintain warmth. 2) Suction infant's mouth and then nose as needed to clear airway. 3) If suction does not stimulate infant to begin crying, attempt manual stimulation by flicking the sole of the infant's foot or rubbing its back. 4) Assess respirations (normal should be 30-60 resps/min) and provide resuscitation if needed. 5) APGAR scoring at 1min and 5 min. If 5min score is <7, repeat Q5 min for 20min or until 2 consecutive scores of >8 are achieved. 6) When pulsations cease (approx 2 min) clamp and cut the cord.

Neonatal Resuscitation:

1. Evaluate respirations and HR.

2. If HR <100 BVM for 30 seconds with room air.

3. If HR is >=60 but <100 repeat BVM with room air for 30 seconds. If HR is <60, administer chest compressions with BVM and 100% oxygen, for 30 seconds (3:1 compression to ventilation ratio).

4. Reassess. If HR >=100 assess colour and provide O2 if centrally cyanotic. If HR <100 - >=60 repeat step 2. If HR <60 Repeat step 3.

Treatment of shoulder dystocia:

If patient presents with obvious signs of shoulder dystocia (ie turtle sign):

A- Ask for help

L- Lift legs and hyperflex thighs (McRoberts Manoeuvre)

A- Adduct anterior shoulder (Suprapubic pressure)

R- Roll over (Gaskin)

M- Manually deliver posterior arm

(McRoberts, Suprapubic pressure, Gaskin, Deliver)

Management of Nuchal or Prolapsed cord:

For cord prolapse:

1)Place patient in knee-chest position (Gaskin).

2)Cradle the cord in hand and insert 2 fingers into the vagina and lift the presenting part off the cord.

Management of Breech delivery:

1. Support the newborn with forearm

2. Have partner apply suprapubic pressure to promote flexion.

3. Once the head is visible, place dominant hand on infant's back with middle finger on back of head to promote flexion.

4. Use Mauriceau-Smellie-Veit Manoeuvre to pivot infant around pubic bone.

Triad for Ectopic pregnancy:

1. Abdominal pain

2. Vaginal bleeding

3. Amenorrhea

Triad for Preeclampsia:

1. Hypertension

2. Peripheral edema

3. Proteinurea

Normal delivery:

1. Place hand in front of baby's head to control delivery.

2. Once head is delivered, tell mom to stop pushing so you can assess airway patency and rue out a nuchal cord.

3. Guide the baby's head and shoulders out. Be ready because they come out fast once the shoulders are delivered.

4. Warm, dry, and stimulate. Follow ALS protocol.

5. Cut cord at 30 sec-2 min.

Placental delivery:

Should deliver 5-60 minutes post-fetal delivery. There will be a small gush of blood and the cord will lengthen. Apply gentle traction and guard the uterus. Check the fundus for tone q5minutes. Prepare for possible hemorrhage.

Postpartum hemorrhage:

If the placenta has not yet been delivered, DO NOT perform external uterine massage. Instead perform manual compression. If the placenta HAS been delivered, uterine massage is acceptable.

Manage hypotension with IV therapy if able.

Load and go situations:

-Prolapse cord: Cradle the cord in a gloved hand and replace it in the vaginal canal. Insert 2 gloved fingers into the canal and elevate the presenting part off of the cord while patient is in exaggerated Sims position.

-Obstructed labor.

-Malpresentation.

-Uncorrected shoulder dystocia after 2 attempts of the ALARM mnemonic.

-Uncorrected postpartum hemorrhage.

-Pre-eclampsia/eclampsia, multiple births expected, or premature labor.

Complicated presentations:

-Shoulder dystocia: Attempt ALARM mnemonic. No more than 2 min in McRobert's or Gaskin positions. Max number of attempts is 2.

-Breech: Allow hands off delivery to the umbilicus. After that guide delivery up to the head. If the head does not deliver within 3 minutes of the body attempt the Smellie-Veight maneuver.