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The Miracle of Life…Almost PRE-DELIVERY COMPLICATIONS
Supine Hypotensive Trauma in Pregnancy Syndrome
• Causes of maternal injury in decreasing order of frequency: • Usually seen 3rd trimester – term – Vehicular crashes – Falls • Problem coincides with supine – Penetrating objects YIKES!! positioning
• The greatest risk of fetal death is from • Fetal/uterine weight compresses the maternal distress IVC
Supine Hypotensive Ectopic Pregnancy Syndrome
• Check to see if volume depletion is • A fertilized ovum implants and develops an issue outside the normal uterine cavity – Orthosatic VS – Hx of diarrhea, vomiting • Sites – Dehydration – Fallopian tubes (95%) • Manage with LLR positioning and – Abdominal cavity fluids – Ovaries
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Ectopic Pregnancy WHY? • Infections – PID, IUD’s, previous abortions • Pelvic/Ovarian tumors • Tubal surgery • Anatomical defect – Rare
Ectopic Pregnancy All women of childbearing age who present with acute Wadda Ya See? onsetTAKE of abdominal NOTE pain and signs or symptoms of shock Depends on how intact the should be considered to tubes are have an ectopic pregnancy until proven otherwise!
Ectopic Pregnancy Ectopic Pregnancy
• Before rupture • After rupture –LMP was usually < 6 weeks –Severe bleeding into the • No more than 8 weeks abdomen –Mild vaginal bleeding or brown- • Vaginal bleeding minimal stained discharge –Mild spasmodic cramping/acute –Compensated/decompensated stabbing pain shock S/S
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Ectopic Pregnancy Placenta Previa OPTIONS ? • Placenta implants partially or • Rapid ABC assessment/recognition completely in the lower part of the
uterus • Priority transport
• Shock management • Happens in 1 in every 200 pregnancies
•
Placenta Previa Placenta Previa
• Low-lying (Type 1) • Marginal (Type 2) • Partial (Type 3) • Complete (Type 4)
Placenta Previa Placenta Previa
• Risk Factors • S/S • Treatments –Age – Bleeding – ABC support • Bright red – I.V. fluid support –Multiparity • Painless – Transport for –Previous C-section • Spontaneous definitive treatment –D&C – Non- tender abdomen • C-Section –Smoking – Fundal height OK
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Abruptio Placenta
• Premature separation of a normally situated placenta in the upper part of the uterus
• Typically a 3rd Trimester complication
Abruptio Placenta Abruptio Placenta • Findings What’s Goin’ On? –Scant outward DARK red blood flow WITH pain • Pre-eclampsia –Acute onset • Chronic HTN –Uterus becomes tender and rigid • Trauma if hemorrhage is retained • Don’t know… –S/S of shock inconsistent with amount of visible bleeding
Abruptio Placenta General Assessment
• Fluid resuscitation prn
• Transport in LLR position
• Definitive tx is C-Section
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Normal Delivery Head and Perineum support
Normal Delivery Normal Delivery
Normal Delivery Normal Delivery
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Normal Delivery Normal Delivery
ABNORMAL DELIVERIES
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Umbilical Cord Presentation
• The umbilical cord presents before the fetal head
• Cord becomes compressed between fetus and pelvis
• Associated with breech presentation, multigravidity, large fetus
Umbilical Cord Presentation Breech Presentation
• Occurs when the fetus’ • Position the mother in a buttocks or lower knee-chest position extremities • Check cord for pulsations are the presenting part and cover cord with sterile towel moistened with saline • Have mother pant with • Increased risk of contractions to avoid prolapsed cord, cord bearing down compression • Insert a sterile, gloved hand into the birth canal and push the presenting part of • Associated with pre- the fetus off the cord term birth, placenta • High flow oxygen previa
Breech Presentation Breech Presentation
• If the head will not deliver, then form a “V” with fingers and press the vagina away from the newborn’s nose
• Temporary airway is established
• Transport with mom’s hips elevated
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Cephalopelvic Disproportion
• Size of the fetus head vs. mom’s pelvis
• One of the most common causes of difficult labor
• The mother is often primigravida and experiencing strong, frequent contractions for a prolonged period
Cephalopelvic Disproportion Cephalopelvic Disproportion
Causes • Remedy • Increased fetal weight –Basic standard of care – >10 lbs. –3 D’s – Diabetic mother • Discovery – Multigravida mother • Delivery to ambulance • Cervical rigidity • Diesel
Shoulder Dystocia Shoulder Dystocia
• Fetal shoulder becomes lodged against the mother’s pubic bone
• Cannot be detected until after the head delivers
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Shoulder Dystocia
• MATERNAL • FETAL – Postpartum bleed – Clavicle fx. – Perineal tear – Humerus fx. – Uterine rupture – Fetal hypoxia – Fracture of – Brachial plexus symphysis pubis injury – Vaginal – Fetal death lacerations
Shoulder Dystocia Meconium Staining
• Be prepared to transport • Light green to immediately in case darker green, delivery is not thick possible
• Intubation/suction • Also be prepared to resuscitate the may be newborn necessary to clear the airway Meconium
Suctioning Meconium Suctioning Meconium
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POSTPARTUM COMPLICATIONS
Postpartum Bleeding Postpartum Bleeding • ABC’s • Loss of more than 500 cc’s of blood immediately following delivery • High flow Oxygen • Caused by: – Lack of uterine tone • Place baby at breast, uterine massage • Multigravida, multiple births, large newborn – Vaginal/Cervical tears • Consider 2 large I.V.’s – Retained placental pieces
• Consider Oxytocin prn
Uterine Rupture Uterine Rupture
• Spontaneous or traumatic rupture of the uterine wall – Occurs in 1 out of 1400 deliveries – 5-15% maternal mortality
• May result from previous uterine scar
• Prolonged labor, trauma
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Uterine Rupture Uterine Inversion
• Characterized by sudden abdominal pain, • Infrequent (0.05% of all deliveries)1 steady tearing sensation, active labor • Uterus gets turned inside-out after delivery • Early signs of shock, weakness, dizzy, may – Umbilical cord traction not see bleeding, abdomen rigid, fetus may – Fundal implantation of placenta be palpated through abdomen
• Inverted uterus usually appears as a • Sudden cessation of labor and/or fetal heart protruding bluish-gray mass tones – Placenta is often still attached
Uterine Inversion
• S/S – Profuse vaginal bleeding • 800ml – 2L – Severe lower abdominal pain – Vasovagal effects
• Treat for shock and bleeding
S2-S4
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THE END… It’s Been My Pleasure… Any Questions? Christopher Ebright B.Ed., NREMT-P
National EMS Academy Covington, LA
Resources Resources
• http://www.w-cpc.org/fetal2.html 1. www.aafp.org/afp/20070315/875.html • http://www.w-cpc.org/fetal1.html • http://www.mhhe.com/socscience/deve • Brady Paramedic CD Vol. 3 l/ibank/image/0038.jpg • http://images.google.com/imgres?imgurl=med • http://www.babiesonline.com/pregnanc lib.med.utah.edu/WebPath/jpeg4/FEM083.jpg &imgrefurl=http://medlib.med.utah.edu/WebP y/monthbymonth/trimester1.asp ath/FEMHTML/FEM083.html&h=331&w=504 • http://ms.yuba.cc.ca.us/vet02/bio/photo &sz=74&tbnid=jl06AA6rJJ0J:&tbnh=84&tbnw s/bio46.jpg =127&start=4&prev=/images%3Fq%3Duterin • http://www.w-cpc.org/fetal3.html e%2Brupture%26hl%3Den%26lr%3D%26ie% 3DUTF-8
Resources
• http://medlib.med.utah.edu/kw/human_reprod/mml/hr ob_oh_5.jpg • Commander Diane Miller, NC, USN • http://www.who.int/reproductive- health/impac/Images_P/3.22.1manualreposit.gif • http://prometheus.frii.com/~jenine/summer98/bman/b aby.jpg • Mosby Paramedic CD ch. 40 • Matthew Zavarella, RN, EMT-P • http://www.med-help.net/ECB1I.jpg • http://www.udel.edu/Biology/Wags/histopage/colorpa ge/cfr/cfrcp.GIF
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