chapter 42 obstetricsbrainspew.com/advanced/medic/slides/chapter_042.pdf · powerpoint lecture...

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Chapter 42Chapter 42ObstetricsObstetrics

Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

ObjectivesObjectivesDescribe organization and function of structures of Describe organization and function of structures of pregnancypregnancy

Outline fetal developmentOutline fetal development

Explain maternal physiological changes during Explain maternal physiological changes during pregnancypregnancy

Describe obstetrical patient history takingDescribe obstetrical patient history taking

Describe assessment of pregnant patientsDescribe assessment of pregnant patients


ObjectivesObjectivesDescribe care of the pregnant patientDescribe care of the pregnant patient

Discuss care after trauma to the mother or fetusDiscuss care after trauma to the mother or fetus

Describe assessment and management of Describe assessment and management of patients with:patients with:

Preeclampsia and eclampsiaPreeclampsia and eclampsiaVaginal bleeding in pregnancyVaginal bleeding in pregnancy


Mosby, Inc. items and derived items © 2007, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

Sanders: Mosby's Paramedic Textbook, Revised 3rd Edition PowerPoint Lecture Notes

Chapter 42: Obstetrics

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ObjectivesObjectivesOutline the changes during laborOutline the changes during labor

Describe the paramedicDescribe the paramedic’’s role during labor and s role during labor and deliverydelivery

Compute an Apgar scoreCompute an Apgar score

Describe assessment and management of Describe assessment and management of postpartum hemorrhagepostpartum hemorrhage

Discuss implications of complicated deliveriesDiscuss implications of complicated deliveries


ScenarioScenarioYour patient is G5P4 and due in 1 week with Your patient is G5P4 and due in 1 week with this pregnancy. She called 9this pregnancy. She called 9--11--1 because she 1 because she had painless vaginal bleeding, but by the time had painless vaginal bleeding, but by the time you arrive, contractions have begun and the you arrive, contractions have begun and the bleeding has increased. As you administer bleeding has increased. As you administer oxygen and start an IV, she becomes pale oxygen and start an IV, she becomes pale and complains of sudden, severe difficulty and complains of sudden, severe difficulty breathing. Her oxygen saturation drops to breathing. Her oxygen saturation drops to 84%.84%.


DiscussionDiscussionWhat could be causing her bleeding?What could be causing her bleeding?

Why did she become short of breath?Why did she become short of breath?

Does her pregnancy history make her high risk for Does her pregnancy history make her high risk for any of these problems?any of these problems?

How will these signs and symptoms affect the fetus?How will these signs and symptoms affect the fetus?

Describe your priorities of care for this patientDescribe your priorities of care for this patient



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Normal Events of PregnancyNormal Events of PregnancyOvulationOvulation

FertilizationFertilizationDistal third of Distal third of fallopian tubefallopian tube

ImplantationImplantationUterusUterus


Specialized Structures of PregnancySpecialized Structures of Pregnancy

PlacentaPlacenta

Umbilical cordUmbilical cord

Amniotic sac and fluidAmniotic sac and fluid


PlacentaPlacentaTransfer of gasesTransfer of gases

Transport other nutrientsTransport other nutrients

Excretion of wastesExcretion of wastes

Hormone productionHormone production

ProtectionProtection



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Umbilical CordUmbilical CordConnects placenta Connects placenta to fetusto fetus

2 arteries and 1vein2 arteries and 1vein


Amniotic Sac and FluidAmniotic Sac and FluidMembrane surrounding fetusMembrane surrounding fetus

Fluid from fetus: Urine, secretionsFluid from fetus: Urine, secretionsAccumulates rapidlyAccumulates rapidly175175--225 mL by 15th week225 mL by 15th weekAbout 1 L at birth About 1 L at birth

Rupture of membraneRupture of membraneWatery dischargeWatery discharge


Fetal Growth and DevelopmentFetal Growth and Development

First 8 weeks of pregnancyFirst 8 weeks of pregnancyEmbryoEmbryo

After that and until birthAfter that and until birthFetusFetus



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Fetal Growth and DevelopmentFetal Growth and Development

GestationGestationPeriod during which intrauterine fetal development Period during which intrauterine fetal development takes placetakes placeAverage 40 wks from fertilization to deliveryAverage 40 wks from fertilization to delivery9090--day periods (trimesters)day periods (trimesters)


Human Embryo and Fetus atHuman Embryo and Fetus at35 Days35 Days


Human Embryo and Fetus atHuman Embryo and Fetus at49 Days49 Days



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Human Embryo and FetusHuman Embryo and Fetusat End of 1st Trimester at End of 1st Trimester


Human Embryo and Fetus atHuman Embryo and Fetus at4 Months 4 Months


Obstetrical TerminologyObstetrical TerminologyGravidaGravida

All current and past pregnanciesAll current and past pregnancies

Para Para Number of past pregnancies viable to deliveryNumber of past pregnancies viable to delivery

AntepartumAntepartumPeriod before deliveryPeriod before delivery

GestationGestationPeriod of intrauterine fetal developmentPeriod of intrauterine fetal development

Grand multiparaGrand multiparaSeven deliveries or moreSeven deliveries or more



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Obstetrical TerminologyObstetrical TerminologyMultiparaMultipara

Two or more deliveriesTwo or more deliveries

NatalNatalConnected with birthConnected with birth

NulliparaNulliparaHas never deliveredHas never delivered

PerinatalPerinatal——occurring occurring At or near time of birthAt or near time of birth

PostpartumPostpartumPeriod after deliveryPeriod after delivery


Obstetrical TerminologyObstetrical TerminologyPrenatal Prenatal

Before birthBefore birth

PrimigravidaPrimigravidaPregnant for first timePregnant for first time

PrimiparaPrimiparaGave birth onceGave birth once

TermTermPregnancy at 40 weeksPregnancy at 40 weeks’’ gestationgestation


Maternal Changes During PregnancyMaternal Changes During Pregnancy

Cessation of menstruationCessation of menstruation

Enlargement of uterusEnlargement of uterus

Other changes affect: Other changes affect: Genital tractGenital tractBreastsBreastsGastrointestinal systemGastrointestinal systemCardiovascular systemCardiovascular systemRespiratory systemRespiratory systemMetabolismMetabolism



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Obstetrical History Obstetrical History Length of gestationLength of gestationParity and gravidityParity and gravidityPrevious cesarean delivery Previous cesarean delivery Maternal lifestyle Maternal lifestyle Infectious disease statusInfectious disease statusPrevious gynecological or obstetrical Previous gynecological or obstetrical complications complications PainPain


Obstetrical HistoryObstetrical HistoryQuantity, character of vaginal bleedingQuantity, character of vaginal bleeding

Abnormal vaginal dischargeAbnormal vaginal discharge

““ShowShow””Expulsion of mucous plug in early laborExpulsion of mucous plug in early labor

Rupture of membranesRupture of membranes

General health and prenatal careGeneral health and prenatal care


Obstetric HistoryObstetric HistoryAllergies, medications takenAllergies, medications taken

Use of narcotics within 4 hrsUse of narcotics within 4 hrs

Urge to bear down Urge to bear down

Sensation of imminent bowel movement Sensation of imminent bowel movement



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Physical ExaminationPhysical ExaminationChief complaint determines examChief complaint determines exam

Rapidly identify acute surgical or lifeRapidly identify acute surgical or life--threatening threatening conditions or imminent deliveryconditions or imminent deliveryTake appropriate management stepsTake appropriate management steps


Physical ExaminationPhysical ExaminationEvaluate general appearance and skin colorEvaluate general appearance and skin color

Assess vital signs and reassess Assess vital signs and reassess

Examine abdomen for previous scars and Examine abdomen for previous scars and any gross deformityany gross deformity


Evaluation of Uterine SizeEvaluation of Uterine Size88--10 weeks10 weeks

Uterine contour irregular Uterine contour irregular

1212--16 weeks16 weeksUterus above symphysis pubisUterus above symphysis pubis

24 weeks24 weeksUterus at level of umbilicusUterus at level of umbilicus

TermTermUterus near xiphoid processUterus near xiphoid process



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Changes in Fundal HeightChanges in Fundal Height


Fetal MonitoringFetal MonitoringFetal heart soundsFetal heart sounds

Auscultate between 16 and 40 wks by Auscultate between 16 and 40 wks by stethoscope, fetoscope, or Dopplerstethoscope, fetoscope, or Doppler

Benefits of fetal monitoringBenefits of fetal monitoring

ProcedureProcedure

Normal fetal heart rate: 120Normal fetal heart rate: 120--160 bpm160 bpm


Fetoscope Fetoscope



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Doppler Doppler


Sites for Auscultation ofSites for Auscultation ofFetal Heart TonesFetal Heart Tones


General Management of OB PatientGeneral Management of OB Patient

If birth not imminent, care for healthy patient often If birth not imminent, care for healthy patient often can be limited to basic treatment modalitiescan be limited to basic treatment modalities

In absence of distress or injury, transport in position In absence of distress or injury, transport in position of comfort:of comfort:

Usually left lateral recumbentUsually left lateral recumbentECG monitoring, oxygen, and fetal monitoring may be ECG monitoring, oxygen, and fetal monitoring may be indicatedindicatedBased on assessment Based on assessment IV access in some patientsIV access in some patients



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Complications of PregnancyComplications of PregnancyTraumaTrauma

Medical conditionsMedical conditions

Pregnancy itselfPregnancy itself

Prior disease processesPrior disease processesAggravated by pregnancyAggravated by pregnancy


Trauma in PregnancyTrauma in PregnancyCauses of maternal injuryCauses of maternal injury

Vehicular crashesVehicular crashesFallsFallsPenetrating objectsPenetrating objects

Greatest risk of fetal deathGreatest risk of fetal deathFetal distress and intrauterine demise caused by Fetal distress and intrauterine demise caused by trauma to mother or her deathtrauma to mother or her death


Trauma in PregnancyTrauma in PregnancyAssess and intervene for motherAssess and intervene for mother

Fetal death from maternal traumaFetal death from maternal trauma

Pregnant trauma patient needs physician Pregnant trauma patient needs physician evaluationevaluation

AssessmentAssessmentSigns of shock can be slow to developSigns of shock can be slow to developDecreased fetal movement/HR may indicate shockDecreased fetal movement/HR may indicate shock



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Trauma in PregnancyTrauma in PregnancyManagementManagement

High concentration oxygen, administer fluidHigh concentration oxygen, administer fluidVasopressors not recommendedVasopressors not recommendedPrepare for laborPrepare for laborAggressive resuscitation if arrestAggressive resuscitation if arrestImmobilize and transport Immobilize and transport

•• Left lateral recumbent positionLeft lateral recumbent position•• Manual uterine displacementManual uterine displacement


Medical Conditions Medical Conditions Pregnancy can mask or aggravate:Pregnancy can mask or aggravate:

AppendicitisAppendicitisCholecystitisCholecystitisHypertensionHypertensionDiabetesDiabetesInfectionInfectionNeuromuscular disordersNeuromuscular disordersCardiovascular diseaseCardiovascular disease


PreeclampsiaPreeclampsiaUnknown causeUnknown cause

Often healthy, normotensive primigravidaOften healthy, normotensive primigravida•• After twentieth week, often near termAfter twentieth week, often near term

Characterized by:Characterized by:VasospasmVasospasmEndothelial cell injuryEndothelial cell injuryIncreased capillary permeabilityIncreased capillary permeabilityActivation of clotting cascadeActivation of clotting cascade



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Preeclampsia and EclampsiaPreeclampsia and EclampsiaDiagnosis of preeclampsiaDiagnosis of preeclampsia

HypertensionHypertension•• Blood pressure >140/90 mm HgBlood pressure >140/90 mm Hg•• Acute rise of 20 mm Hg in systolic pressureAcute rise of 20 mm Hg in systolic pressure

OROR•• 10 mm Hg rise in diastolic pressure over prepregnancy 10 mm Hg rise in diastolic pressure over prepregnancy

levelslevelsProteinuriaProteinuriaExcessive weight gain with edemaExcessive weight gain with edema

Treat hypertension, prevent seizuresTreat hypertension, prevent seizures


EclampsiaEclampsiaSame signs and symptoms plus seizures or comaSame signs and symptoms plus seizures or coma

TonicTonic--clonic activityclonic activity

Often begins as oral twitchingOften begins as oral twitching

Often apnea during seizureOften apnea during seizure

Can initiate laborCan initiate labor


EclampsiaEclampsia——ManagementManagementLeft lateral recumbent positionLeft lateral recumbent position

Minimize stimulationMinimize stimulation

Oxygen and ventilation assistanceOxygen and ventilation assistance

IVIV

If seizures:If seizures:Magnesium sulfateMagnesium sulfateDiazepamDiazepamMonitor vital signsMonitor vital signs



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Gestational Diabetes MellitusGestational Diabetes MellitusMother canMother can’’t metabolize carbohydratest metabolize carbohydrates

Excess glucose goes to fetusExcess glucose goes to fetusStored as fatStored as fat

TreatmentTreatmentGlucose monitoringGlucose monitoringDietDietExerciseExerciseInsulinInsulin


Vaginal BleedingVaginal BleedingAbortion (miscarriage)Abortion (miscarriage)

Ectopic pregnancyEctopic pregnancy

Abruptio placentaeAbruptio placentae

Placenta previaPlacenta previa

Uterine ruptureUterine rupture

Postpartum hemorrhagePostpartum hemorrhage


AbortionAbortionTermination of pregnancy from any cause before 20Termination of pregnancy from any cause before 20thth

week of gestationweek of gestationLater is known as Later is known as preterm birthpreterm birth

Common classifications of abortionCommon classifications of abortion

Determine:Determine:Onset of pain and bleedingOnset of pain and bleedingAmount of blood lossAmount of blood lossIf any tissue passed with bloodIf any tissue passed with blood

ManagementManagement



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Ectopic PregnancyEctopic PregnancyOvum implants outside uterusOvum implants outside uterus

CommonCommon

Predisposing factors Predisposing factors

Classic triad of symptomsClassic triad of symptomsAbdominal painAbdominal pain

•• Shoulder painShoulder painVaginal bleedingVaginal bleedingAmenorrheaAmenorrhea

•• May not be presentMay not be present


Ectopic PregnancyEctopic PregnancyCan result in frank shockCan result in frank shock

True emergencyTrue emergency

Requires rapid transport for surgeryRequires rapid transport for surgery

Manage for hemorrhagic shockManage for hemorrhagic shock


ThirdThird--Trimester BleedingTrimester Bleeding3% of pregnancies3% of pregnancies

Never normalNever normal

Most often due to:Most often due to:Abruptio placentaeAbruptio placentaePlacenta previaPlacenta previaUterine ruptureUterine rupture



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Abruptio PlacentaeAbruptio PlacentaePartial or complete detachment of normally Partial or complete detachment of normally implanted placenta at more than 20 weeksimplanted placenta at more than 20 weeks’’gestationgestation

Predisposing factorsPredisposing factorsTraumaTraumaMaternal hypertensionMaternal hypertensionPreeclampsiaPreeclampsiaMultiparityMultiparityPrevious abruptionPrevious abruption


Abruptio PlacentaeAbruptio PlacentaeSudden vaginal bleeding in 3Sudden vaginal bleeding in 3rdrd trimester trimester

PainPainAbdomen may be tender or rigidAbdomen may be tender or rigid

May be minimal bleeding with shockMay be minimal bleeding with shockMost of hemorrhage may be hiddenMost of hemorrhage may be hidden

Contractions may be presentContractions may be present

If fetal heart tones absent, fetal death is likelyIf fetal heart tones absent, fetal death is likely


Placenta PreviaPlacenta PreviaPlacental implantation in lower uterine Placental implantation in lower uterine segment, encroaching on or covering cervical segment, encroaching on or covering cervical osos

1 in 300 deliveries1 in 300 deliveriesMore common in preterm birthMore common in preterm birth

Painless, bright red bleedingPainless, bright red bleedingIncreases if labor beginsIncreases if labor beginsFetal compromiseFetal compromise



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Placenta PreviaPlacenta PreviaMore common with:More common with:

Increased maternal ageIncreased maternal ageMultiparityMultiparityPrevious cesarean sectionPrevious cesarean sectionPrevious placenta previaPrevious placenta previa


Uterine RuptureUterine RuptureSpontaneous or traumatic rupture of uterine wallSpontaneous or traumatic rupture of uterine wall

CausesCausesPrevious scar opensPrevious scar opensTraumaTraumaProlonged or obstructed laborProlonged or obstructed labor

Rare but accounts for 5%Rare but accounts for 5%--15% maternal deaths15% maternal deaths50% of fetal deaths50% of fetal deaths


Uterine RuptureUterine RuptureSudden abdominal painSudden abdominal pain

““TearingTearing””

Active laborActive labor

Early signs of shockEarly signs of shock

Vaginal bleedingVaginal bleedingMay be hiddenMay be hidden



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Management of 3Management of 3rdrd Trimester BleedingTrimester BleedingPrevent shockPrevent shock

Do not examine patient vaginallyDo not examine patient vaginallyMay increase bleeding and start laborMay increase bleeding and start labor

Emergency care Emergency care ABCsABCsLeft lateral recumbent positionLeft lateral recumbent positionIV therapyIV therapyCheck fundal heightCheck fundal height


Labor and DeliveryLabor and DeliveryProcess by which infant is bornProcess by which infant is born

Uterus progressively more irritableUterus progressively more irritable

Cervix begins to dilate:Cervix begins to dilate:Complete dilation is 10 cmComplete dilation is 10 cm

Amniotic sac ruptureAmniotic sac rupture

Fetus and then placenta are expelledFetus and then placenta are expelled


Parturition Parturition



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Stages of LaborStages of LaborStage 1 Stage 1

Onset of regular contractionsOnset of regular contractionsEnds with complete dilation of cervixEnds with complete dilation of cervix

Stage 2Stage 2From full dilation of cervix to delivery of infantFrom full dilation of cervix to delivery of infant

Stage 3Stage 3Begins at delivery of infantBegins at delivery of infantEnds when placenta has been expelled and uterus has Ends when placenta has been expelled and uterus has contractedcontracted


Signs and Symptoms ofSigns and Symptoms ofImminent DeliveryImminent Delivery

Prepare for delivery if:Prepare for delivery if:Regular contractions lasting 45Regular contractions lasting 45--60 sec at 160 sec at 1--2 min 2 min intervalsintervalsUrge to bear down or sensation of bowel movementUrge to bear down or sensation of bowel movementLarge amount of bloody showLarge amount of bloody showCrowning occursCrowning occursMother believes delivery is imminentMother believes delivery is imminent


Signs and Symptoms ofSigns and Symptoms ofImminent DeliveryImminent Delivery

Do not delay or restrain delivery except for cord Do not delay or restrain delivery except for cord presentationpresentation

If complications are anticipated or abnormal delivery If complications are anticipated or abnormal delivery occurs, medical direction may recommend expedited occurs, medical direction may recommend expedited transport to a medical facilitytransport to a medical facility

Preparing for deliveryPreparing for delivery

Delivery equipmentDelivery equipment



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Prehospital Delivery EquipmentPrehospital Delivery Equipment


Assisting with DeliveryAssisting with DeliveryAssist in natural events of childbirthAssist in natural events of childbirth

Responsibilities of EMS crew:Responsibilities of EMS crew:Prevent uncontrolled deliveryPrevent uncontrolled deliveryProtect infant from cold stress after birthProtect infant from cold stress after birth


Assisting with a Normal DeliveryAssisting with a Normal Delivery

Delivery procedureDelivery procedure

Evaluating infantEvaluating infant

Cutting umbilical cordCutting umbilical cord

Delivery of placentaDelivery of placenta

Fundal massage to promote uterine contractionFundal massage to promote uterine contraction



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Normal DeliveryNormal DeliveryWhen crowning, apply gentle pressure to infant’s head


Normal DeliveryNormal DeliveryExamine neck for looped umbilical cord


Normal DeliveryNormal DeliverySupport infant’s head as it rotates for shoulder presentation



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Normal DeliveryNormal DeliveryGuide infant’s head downward to deliver anterior shoulder


Normal DeliveryNormal DeliveryGuide head upward to release posterior shoulder


DeliveryDeliveryAfter delivery and evaluation of infant, clamp and cut cord



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Is Resuscitation Needed?Is Resuscitation Needed?

Full term gestation?Full term gestation?Clear amniotic fluid?Clear amniotic fluid?Is baby breathing or crying?Is baby breathing or crying?Does the baby have good muscle tone?Does the baby have good muscle tone?If yes to all four questions If yes to all four questions

Need to resuscitate is unlikelyNeed to resuscitate is unlikely


Postpartum HemorrhagePostpartum Hemorrhage>500 mL of blood loss after delivery >500 mL of blood loss after delivery

Immediate or delayed 24 hrsImmediate or delayed 24 hrs

Risk factorsRisk factorsUterine atony from laborUterine atony from laborGrand multiparityGrand multiparityTwinsTwinsPlacenta previaPlacenta previaFull bladderFull bladder


Postpartum HemorrhagePostpartum HemorrhageControl external hemorrhageControl external hemorrhage

Massage uterusMassage uterus

Encourage infant to breast feedEncourage infant to breast feed

Administer oxytocinAdminister oxytocin

DonDon’’t attempt vaginal examt attempt vaginal exam

Rapid transportRapid transport



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Delivery ComplicationsDelivery ComplicationsMaternal factorsMaternal factors

AgeAgeNo prenatal careNo prenatal careLifestyleLifestylePreexisting illnessPreexisting illnessPrevious OB historyPrevious OB historyIntrapartum disordersIntrapartum disorders


Delivery ComplicationsDelivery ComplicationsFetal factorsFetal factors

Lack of fetal wellLack of fetal well--beingbeingDecreased fetal movementDecreased fetal movementHistory of heart rate abnormalitiesHistory of heart rate abnormalitiesFetal immaturityFetal immaturityFetal growthFetal growth


Cephalopelvic Disproportion Cephalopelvic Disproportion Difficult labor because of:Difficult labor because of:

Small pelvisSmall pelvisOversized fetusOversized fetusFetal abnormalitiesFetal abnormalities

•• Hydrocephalus, conjoined twins, fetal tumorsHydrocephalus, conjoined twins, fetal tumors

Often primigravida experiencing strong, frequent Often primigravida experiencing strong, frequent contractions for long periodcontractions for long period



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Cephalopelvic Disproportion Cephalopelvic Disproportion Prehospital carePrehospital care

Maternal oxygen administrationMaternal oxygen administrationIV access for fluid resuscitation if neededIV access for fluid resuscitation if neededRapid transport to receiving hospitalRapid transport to receiving hospital


Abnormal PresentationAbnormal PresentationMost infants born head firstMost infants born head first

Cephalic or vertex presentationCephalic or vertex presentationRarely abnormal presentationRarely abnormal presentation

Breech presentationBreech presentationManagementManagement

Shoulder dystociaShoulder dystociaManagementManagement

Shoulder presentation (transverse presentation)Shoulder presentation (transverse presentation)ManagementManagement


Breech Presentations Breech Presentations



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Abnormal PresentationAbnormal PresentationCord presentation (prolapsed cord)Cord presentation (prolapsed cord)

Elevate motherElevate mother’’s hipss hipsMaternal oxygenMaternal oxygenHave mother pant with contractionsHave mother pant with contractionsApply moist, sterile dressing to cordApply moist, sterile dressing to cordGently push infant back into vaginaGently push infant back into vagina

•• Elevate presenting partElevate presenting part•• Maintain during transportMaintain during transport


Other Abnormal PresentationsOther Abnormal PresentationsFace or browFace or brow

Occiput posterior presentationOcciput posterior presentationFace upFace up

Increased perinatal morbidity and mortalityIncreased perinatal morbidity and mortality

Early recognition criticalEarly recognition critical


Abnormal PresentationAbnormal PresentationPrehospital managementPrehospital management

Recognition of potential complicationsRecognition of potential complicationsMaternal support and reassuranceMaternal support and reassuranceRapid transport for definitive careRapid transport for definitive care



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Premature Birth Premature Birth Birth at <37 weeks of gestationBirth at <37 weeks of gestation

Care of premature infantCare of premature infantKeep warmKeep warmSuction mouth and nares oftenSuction mouth and nares oftenMonitor cord for oozingMonitor cord for oozingAdminister oxygenAdminister oxygen

•• Monitor for need to assist ventilationsMonitor for need to assist ventilationsGently transportGently transport


Multiple GestationMultiple GestationMore than one fetusMore than one fetus

Associated complicationsAssociated complicationsPremature labor and deliveryPremature labor and deliveryPremature rupture of membranesPremature rupture of membranesAbruptio placentaeAbruptio placentaePostpartum hemorrhagePostpartum hemorrhageAbnormal presentationAbnormal presentation

Delivery procedureDelivery procedure


Multiple GestationMultiple GestationDelivery procedureDelivery procedure

Deliver first twin as normal birthDeliver first twin as normal birthCut and clamp cordCut and clamp cordSecond twin delivery within 30Second twin delivery within 30--45 min45 min

•• Medical direction may recommend transportMedical direction may recommend transport

Keep warmKeep warmMonitor for severe postpartum hemorrhageMonitor for severe postpartum hemorrhage



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Precipitous DeliveryPrecipitous DeliveryRapid spontaneous deliveryRapid spontaneous delivery

Less than 3 hrs from onset of labor to birthLess than 3 hrs from onset of labor to birth

Overactive uterine contractions and little Overactive uterine contractions and little maternal soft tissue or bony resistancematernal soft tissue or bony resistance

Apply gentle counterpressure to headApply gentle counterpressure to head


Uterine InversionUterine InversionRare serious complication of childbirthRare serious complication of childbirth

Uterus turns inside outUterus turns inside outAfter contraction, sneezing, coughingAfter contraction, sneezing, coughingIatrogenicIatrogenic

Signs and symptomsSigns and symptomsProfuse postpartum hemorrhageProfuse postpartum hemorrhageSevere lower abdominal painSevere lower abdominal pain


Uterine InversionUterine InversionManagementManagement

Position patient supinePosition patient supinePush fundus up through cervical canal orPush fundus up through cervical canal orCover with moist sterile dressingsCover with moist sterile dressingsRapid transportRapid transportMedical direction may advise use of analgesicsMedical direction may advise use of analgesics



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Pulmonary EmbolismPulmonary EmbolismPregnancy, labor, or postpartum periodPregnancy, labor, or postpartum period

Common cause of maternal deathCommon cause of maternal death

Often blood clot from pelvisOften blood clot from pelvis

More common with cesarean deliveryMore common with cesarean delivery


Pulmonary EmbolismPulmonary EmbolismSigns and symptomsSigns and symptoms

DyspneaDyspneaSharp chest painSharp chest painTachycardia, tachypneaTachycardia, tachypneaHypotension possibleHypotension possible

ManagementManagementABCsABCsECG and IVECG and IVTransportTransport


Fetal Membrane Disorders Fetal Membrane Disorders Premature rupture of membranesPremature rupture of membranes

Amniotic sac rupture before laborAmniotic sac rupture before labor““TrickleTrickle”” or sudden gush of fluid from vaginaor sudden gush of fluid from vaginaInfection possible if delivery delayedInfection possible if delivery delayedTransport Transport



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Fetal Membrane Disorders Fetal Membrane Disorders Amniotic fluid embolismAmniotic fluid embolism

Amniotic fluid gains access to maternal circulation:Amniotic fluid gains access to maternal circulation:•• During labor or deliveryDuring labor or delivery•• Immediately after deliveryImmediately after delivery

Signs and symptomsSigns and symptomsSame as for pulmonary embolismSame as for pulmonary embolismHigh mortality High mortality

ManagementManagementAs for pulmonary embolismAs for pulmonary embolism


ConclusionConclusionObstetrical emergencies can develop Obstetrical emergencies can develop

suddenly and become life threatening. The suddenly and become life threatening. The paramedic must be prepared to recognize paramedic must be prepared to recognize

and manage these events.and manage these events.


Questions?Questions?



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