Understanding Obstetrics: Complications and Management in Pregnancy and Childbirth

1. Obstetrics

2. Pregnancies • Most are uncomplicated • Complications can arise from: • Eclampsia/Pre-eclampsia • Diabetes • Hypotension/Hypertension • Cardiac disorders • Abortion • Trauma • Placenta abnormalities

3. Childbirth • Involves Labor and Delivery • Natural process, often only requiring basic assistance

4. Childbirth • You have at least two patients!

5. Childbirth • Complications can occur • Breech/limb presentation • Multiple Births • Umbilical cord problems • Disproportion • Excessive bleeding • Pulmonary embolism • Neonate requiring resuscitation • Preterm labor

6. Female Reproductive System

7. Female Reproductive System

9. Anatomy/Physiology • Ovulation • Fertilization • Implantation

10. Anatomy/Physiology • Placenta • Transfer of gases • Transport of nutrients • Excretion of wastes • Hormone production • Protection

11. Anatomy/Physiology • Umbilical cord • Connects placenta to fetus • Two arteries • One vein • Amniotic Sac • Membrane surrounding fetus • Fluid originates from feral sources • 500 - 1000 cc (after 20 weeks) • Rupture produces watery discharge

12. Terminology • Antepartum - before delivery • Postpartum - after delivery • Prenatal - occurring before the birth • Natal - connected with birth • Gravida - number of pregnancies • Para - number of pregnancies carried to full term • Abortion - number of pregnancies that ended before full term • Primigravida - woman who is pregnant for the first time • Primipara - woman who has given birth to her first child • Multiparous - woman who has given birth multiple times • Gestation - period of time for intrauterine fetal development

13. Fetal Growth Process • End of third month • Sex may be distinguished • Heart is beating • Every structure found at birth is present • End of fifth month • Fetal heart tones can be detected • Fetal movement may be felt by mother • End of sixth month • May be capable to survive if born prematurely • Middle of tenth month • Considered to have reached full term • Expected date of confinement (EDC)

14. Ectopic Pregnancy • Pathophysiology • Outside uterine cavity • 95% Fallopian tubes • 1 in every 200 pregnancies • Most are symptomatic • Predisposing factors • Tubal infections • Previous tubal surgery • IUD use • previous ectopic pregnancy

15. Ectopic Pregnancy • History • Missed period • Other signs of early pregnancy • Vaginal bleeding 6 -8 weeks after last period • Upon rupture, bleeding may be excessive

16. Ectopic Pregnancy • History • Lower abdominal pain • May be: • Sharp or dull • Constant or intermittent • Diffuse or localized • May be referred to shoulder

17. Ectopic Pregnancy • Physical Exam • S/S of hypovolemic shock • Positive tilt test • Tender lower abdomen • Palpable mass may be present

18. Ectopic Pregnancy Abdominal pain or unexplained hypovolemia + woman of child-bearing age = Ectopic pregnancy Until proven otherwise!

19. Ectopic Pregnancy • Management • High concentration oxygen • IV or IV’s with LR • MAST • Immediate transport

20. Abortion Termination of pregnancy before fetal viability (20th week)

21. Abortion • Induced • Therapeutic • Criminal • Elective

22. Abortion • Spontaneous • 20 -25% of pregnancies terminate spontaneously • Usually due to embryo abnormalities • May also result from infection, unfavorable intrauterine environment, cervical incompetence

23. Abortion • Spontaneous • Threatened • Inevitable • Complete • Incomplete

24. Abortion • Threatened • Vaginal bleeding, mild or absent contractions, closed cervix • 20% of women bleed in early pregnancy • 50% go on to abort • Any bleeding in early pregnancy is dangerous and abnormal

25. Abortion • Inevitable • Vaginal bleeding • Moderately severe contractions • Possible amniotic sac rupture • Cervix effacement and dilation • Changes are irreversible

26. Abortion • Completed • Products of conception expelled • fetus • placenta • decidual lining • Signs, symptoms • Profuse vaginal bleeding • Passage of tissue, clots • Continuing mild contractions • Possible hypotension

27. Abortion • Incomplete • Products of conception retained • Signs, symptoms • Profuse bleeding • Passage of tissue/clots • Severe contractions • Hypotension, shock • Sepsis

28. Abortion • Missed • Fetus dies in utero before 20th week • Retained at least 2 months afterwards

29. Abortion • Missed • Signs/Symptoms • Continued amenorrhea • History of bleeding without cramping • Decrease in uterine size • Resorption of fluid • Calcification of products of conception

30. Abortion • History • Confirmed or suspected pregnancy • Abdominal pain, cramping • Bleeding, passage of tissue

31. Abortion • Physical Exam • Orthostatic vital signs (tilt test) • Examine for amount of vaginal bleeding, presence of tissue

32. Abortion • Management • High concentration oxygen • IV or IV’s with LR • MAST if indicated • Do NOT pack vagina • Save any tissue passed • Transport

33. Medical Complications • Diabetes • Stable may become unstable • Gestational • Can not use oral medications • Neuromuscular • May be aggravated by pregnancy

34. Medical Complications • Hypertension • More susceptible to complications • CVA • Cardiac Failure • Renal Failure • May be complicated by preeclampsia or eclampsia • Cardiac Disorders • Additional stress placed on heart • CO increases 30% by week 34

35. Pregnancy-Induced Hypertension • Two Phases: • Pre-eclampsia • Eclampsia

36. Pre-Eclampsia • In about 7% of pregnancies • Between 20th week gestation, first week postpartum • Hypertension, albuminuria, edema

37. Pre-Eclampsia • Risk Factors • First pregnancies • Multiple gestations • excessive amniotic fluid • Diabetes mellitus • Renal disease • Pre-existing hypertension • Family history of pre-eclampsia • Poor nutrition

38. Pre-Eclampsia • Signs/Symptoms • Elevated BP • >140/90 or >30mmHg above patient normal • Edema of face/hands • Especially in morning

39. Pre-Eclampsia • Signs/Symptoms • Rapid weight gain • >3lb/wk - 2nd trimester • >1lb/wk - 3rd trimester • Decreased urine output

40. Pre-Eclampsia • Signs/Symptoms • Severe headache • Blurred vision • Irritability • Nausea, vomiting • Epigastric pain • Pulmonary edema

41. Eclampsia Pre-eclampsia + Seizures, Coma

42. PIH • Management • High concentration oxygen • IV tko • Left lateral recumbent position • Quiet environment • Reduce excessive light

43. PIH • Psychological support • Avoid lights/sirens in pre-eclampsia • Magnesium sulfate • 4gm bolus; 1gm/hr infusion • Monitor pulse, BP, respiration, patellar reflex • Calcium will reverse toxicity

44. PIH • Assess every pregnant patient for: • Increased BP • Edema • Take all reported seizures in pregnant females seriously

45. Third Trimester Bleeding • 50% due to normal changes in cervix • 50% due to placental catastrophe • Dangerous if amount greater than normal period

46. Abruptio Placentae • Premature placental separation from uterus • 0.4 - 3.5% of pregnancies • Risk Factors • Older patients • Hypertensives • Multigravidas • Trauma

47. Abruptio Placentae • Mild to moderate vaginal bleeding • Continuous, knife-like abdominal pain • Third trimester pain = Abruption until proven otherwise • Rigid tender uterus • S/S of hypovolemia • Out of proportion to visible bleeding • Alteration of contraction pattern

48. Placenta Previa • Placental implantation over cervical opening • 0.5% of pregnancies • Predisposing factors • increasing age • multiparity • previous cesarean sections • Can lead to • placental insufficiency • fetal hypoxia

49. Placenta Previa • Painless, bright-red vaginal bleeding • Soft, non-tender uterus • No contractions • S/S of hypovolemia

50. Third Trimester Bleeding • Management • 100% Oxygen • IV of LR x 2 • Left lateral recumbent position • MAST, legs only • Assess fetal heart tones?