OB &GYN

Question 1

Changes in pregnancy:

1. Reproductive system (4)
2. Respiratory (5)
3. Cardiovascular (4)
4. GI (2)
5. Urinary (4)
6. musculoskeletal (2)

Answer 1

1. Reproductive system (4)
   - uterus b4 prego-2 oz holds 10ml; end of preg 2 lbs holds 5000ml
   - preg vascular uterus 1/6 of total blood vol
   - mucus plug opening of cervix
   - breast enlarge nodular for lactation
2. Respiratory (5)
   - O2 demand increase
   - resp tract resistance decrease hormone smooth muscle dilation
   - tidal vol increase 40%
   - resp rate increase slightly
   - increase O2 consumption, 20%
3. Cardiovascular (4)
   - CO increase
   - maternal blood volume increase 45%, incr RBC & plasma, but plasma greater=anemia
   - HR incr by 10-15 bmp
   - BP decr slight 1st 2nd trimester and then normal
4. GI (2)
   - N/V 1st trimester need for carbs
   - bloating constipation decr peristalsis
5. Urinary (4)
   - renal blood flow incr
   - GF incr 50% 2nd trimester
   - bladder displaced superiorly anteriorly (incr risk injury)
   - urine frequent
6. musculoskeletal (2)
   - pelvic joints loosen due to hormone
   - change in center of gravity

Question 2

spontaneous abortion

1. pathophysiology (3)
2. assessment (3)

Answer 2

1. pathophysiology
   - 80% occurs prior to 12th weeks 1st tri
   - 15-20% in preg genetics or uterine abnormality, infection, drugs, maternal dx
   - cramping & vaginal bleeding 8-12 wks
2. assessment
   - cramplike lower abd like labor or menstrual cramps
   - moderate-severe vaginal bleeding
   - passage of tissue or blood clots

Question 3

Placenta previa

1. pathophysiology (3)
   1a. 3 types
   1b. predisposing factors (6)
2. assessment (1)

Answer 3

1. pathophysiology (3)
   - major cause of 3rd tri bleeding
   - abnormal implantation of placenta over or near opening of cervix (normal in fundus & posteriorly)
   - bleeding not associated with abnormal uterine contraction or pain
   - Total:completely covers os block birth canal and prevent delivery
   - partial: may obstruct
   - marginal: near neck of cervix
   - predisposing factors: multiparity, rapid succession of preg, greater than 35, previa previa, hx vaginal bleeding, bleeding after intercourse
2. assessment (1)
   - 3rd trimester bleeding painless

Question 4

Abruptio Placentae

1. pathophysiology (1)
   1a. causes problems (
   1b. types (2)
   1c. predisposing factors (8)
2. assessment (7)

Answer 4

1. pathophysiology (3)
   - small arteries lining btw placenta and uterus prone to rupture–>accumulate blood tear & separate placenta from uterine wall
   1a. causes (20: poor gas exchange, waste btw fetus & placenta; severe maternal blood loss
   1b. types (2): complete and partial
   1c. predisposing factors:
   - HTn
   - cocaine vasoactive drugs
   - preeclampsia
   - multiparity
   - previous abruption
   - short umbilical cord
   - premature rupture of amniotic sac
   - DM
2. assessment (7)
   - vaginal blleeding constant abd pain (hallmark)
   - abd pain due to muslce spasm
   - pain lower back
   - uterine contraction
   - abdomen tender
   - vaginal bleed varies in amount
   - S&S hypovolemic shock present

Question 5

Ruptured uterus

1. pathophysiology
2. Assessment

Answer 5

1. pathophysiology
   - uterine enlarge in preg and thin around cervix
   - lead to rupture wall and release fetus into abd cavity
   - 5-20% maternal mortality and >50% infant mortality
   - rupture requires immediate surgery
2. Assessment
   - hx previous rupture
   - hx abdominal trauma
   - hx large fetus
   - multiparity
   - hx prolonged & difficult labor
   - hx C-sec or uterine surgery
   - tearing or shearing sensation in abdomen
   - constant & severe abd pain
   - nausea
   - S&S shock (hypoperfusion)
   - vaginal bleeding
   - cessation of uterine contraction
   - palpatable infant in abd cavity

Question 6

Description of perineal injuries:

1. vascularity
2. causes
3. management

Answer 6

1. very vascular, large blood loss, painful
2. sexual assault,
   - straddle injury from bicycle
   - gymnastics
   - lacerations or hematomas
   - urethral injuries
3. control bleeding with direct pressure
   - apply ice pack

Question 7

1. menstrual cycle how often?
2. what happens?
3. where is the fertilization occurs and after how many days?
4. no fertilization?

Answer 7

1. every 28 days egg released
2. blood supply to uterus increases, wall thickens
3. implant in uterus wall after 7 days
4. egg, extra blood, tissue discarded=period

Question 8

Understand anatomic and physiologic

changes of pregnancy

Answer 8

Changes:

Question 9

Identify 5 pre-delivery emergencies

Answer 9

• Bleeding in early pregnancy
• Threatened abortion/still birth
• Pre-eclampsia and eclampsia
• Trauma in pregnancy
• Ruptured uterus

Question 10

what is a placenta?

Answer 10

• Vascular organ
• Exchange area for nutrients, O2
• Expelled after birth

Question 11

Umbilical Cord

Answer 11

• 2 way blood flow
• 3 vessels surrounded by clear
protective (1 veins, 2 arteries)

Question 12

Amniotic sac

Answer 12

• Grows from placenta
• Encases fetus
• 16-32 ounces of clear watery liquid

Question 13

5 Pregnancy changes in Cardiovascular

-three result of hypovolemia

Answer 13

1. plasma volume up 50%
2. RBC up 18-30%
3. pulse up 15-20 bpm
4. BP lower than normal
5. Hypovolemia
   - response is constriction of uterine arteries
   - redirect flow to major organs
   - can be intensified with position of patient

Question 14

Supine hypotensive syndrome of pregnancy (3)

Answer 14

• Fetus presses on inferior
vena cava
• Inhibits venous return to
the heart
• Decreases cardiac output

Question 15

4 changes in Pregnancy - Pulmonary

Answer 15

§ Respiratory rate – same or slightly increased
§ Tidal volume up 50%
§ O2 demand increased
§ Progesterone relaxes muscle
• feeling of air hunger

Question 16

3 changes in preganncy-GI

-what effects does progesterone have on GI (3)

Answer 16

§ Uterus physically crowds abdominal contents
§ Assume stomach is full
§ Aspiration is possible

progesterone has a slowing effect on GI tract

1. decreased rate of gastric emptying
2. food remains in stomach for longer time
3. relaxation of sphincter btw stomach and esophagus

Question 17

2 changes in pregnancy-uterus

-2 effects of increased blood flow to uterus?

Answer 17

§ Uterus is more susceptible to injury as it
leaves the bony pelvis and acts as barrier for
other organs

§ Blood flow to uterus is enhanced
• Increased vascularity is serious if uterus is injured
• Pelvic fractures cause severe blood loss

Question 18

1. location of ectopic pregnancy
2. time frame
3. mistaken for
4. 9 description of Ectopic pregn

Answer 18

§ Ectopic pregnancy
• 90% occur in fallopian tubes
§ 4 to 6 weeks pregnant
§ Often mistaken for
appendicitis

1. History of amenorrhea
2. Positive pregnancy test result
3. Abdomen swollen
4. Patient may not tell/ know she is pregnant
5. Bleeding usually light
6. Poorly localized lower abdominal pain
7. Pain may radiate to shoulder area and may
   be severe
8. Some vaginal or rectal pain may be present
9. Nausea and vomiting

Question 19

management of Ectopic pregnancy

Answer 19

• if pt lost much blood->tx for shock if hypovolemia symptoms are present
• life threatening

Question 20

Placentia Previa (3)

Answer 20

§ Placentia Previa
• Occurs when placenta
implants over cervix
• Painless bleeding in late
pregnancy
• No way to diagnose
prehospital

Question 21

Placental Abruption

Answer 21

Placental Abruption
• Premature separation of placenta from uterus after 20 weeks gestation
• Sudden onset intense abdominal pain

Question 22

Risk factors of placental abruption

• is bleeding present?
• what needs to be monitor

Answer 22

• Hypertension
• Preeclampsia
• Cocaine use
• Trauma – direct blow or accel/decel force

-Vaginal bleeding not
always present
- Need fetal monitoring

Question 23

Treatment of Placental Abruption

Answer 23

§ Treatment
• Focus is on prevention and treatment of shock
• Place patient on her left side
• Elevate hips with pillows to alleviate pressure on the cervix
• Administer O2
• Monitor vital signs

Question 24

1. Abortion before 30 wks, after 20wks
2. early premie viability
3. signs of abortion/miscarriage

Answer 24

§ Abortion/miscarriage
• Loss of pregnancy before 20 wks gestation
• Stillbirth - after 20 wks
• Earliest age of viability that an infant can survive
outside the womb is approximately 23 wks
§ Signs
• Loss of substantial amount of blood
• Leaking of amniotic fluid in the 1st trimester

Question 25

what is the second leading cause of maternal death? | -list 6 symptoms of it

Answer 25

Pre-eclampsia/eclampsia -2nd leading cause of maternal death in US -Symptoms include: • BP > 160-180 • Decreased urine • Visual changes • Pulmonary edema • Seizures • Bleeding disorders

Question 26

tx for pre/eclampsia

Answer 26

§ Treatment • Provide quiet, dark environment • Use soft voice; avoid jostling or noise • Have suction available in case a seizure begins • If seizures occur, administer O2 • Transport in left lateral recumbent position -can occur after 20 days postpartum

Question 27

first leading cause of maternal death - what can prevent/reduce severity? - increase pressure from lap belt cause (3)

Answer 27

§ MVCs are responsible for majority of all injuries • Injury is less severe if mother is wearing a seat belt with shoulder restraint • Sudden increase in pressure from lap belt alone can cause: • Burst-balloon uterine rupture • Abruptio placentae • Fetal death

Question 28

1. premature labor by blunt trauma cause (3) 2. fetal outcome determined from trauma? 3. what causes uterine lacerations?

Answer 28

1. uterine stimulation by blunt trauma: -Precipitate labor contractions • Cause premature membrane rupture • Abruptio placentae 2. Fetal outcome determined by: • Extent of placental abruption • Rapidity of treatment • Fetus age 3.broken ribs or pelvic bones

Question 29

Treating pregnant trauma victim

Answer 29

``` Treating pregnant trauma victim • Recall physiologic changes of pregnancy • Assume stomach is full • Treating 2 patients • Prevent shock • Spinal precautions • Initial ABCs • Pregnant transport position ``` § Patients beyond the 20th week should be tilted 15° to the left § Place rolled towels beneath the spinal board § Can get supine hypotension syndrome when uterus compresses inferior vena cava § Can decrease cardiac output by up to 30%

Question 30

So what happens if your pregnant patient | codes?

Answer 30

``` § ABC’s § Adequate chest compressions with patient tilted to the left § ACLS protocols § Transport to nearest facility ASAP ```

Question 31

Symptoms (3) of uterine rupture | -9 risk factors

Answer 31

§ Symptoms • Pain • Bleeding with shock • Cessation of contractions ``` § Risk Factors • Prior cesarean section • Prior rupture • Trauma • Injury from instrumentation • Uterine anomalies • Malpresentation • Fetal anomaly • Obstructed labor • Excessive uterine stimulation due to crack-cocaine ```

Question 32

1st stage o labor | -contraction is timed?

Answer 32

``` 1st stage • First contraction to full cervical dilation • Intermittant contractions • NOT Braxton Hicks § Contractions • Timed from beginning of 1 to beginning of next • Become more painful, longer & closer together • Bloody show may be seen • Amniotic sac may break any time ```

Question 33

2nd stage of labor

Answer 33

``` § 2nd stage • “Pushing stage” • Begins when cervix dilated • Ends with birth • Usually 1+ hours with 1st baby • Pressure on the rectum by fetal head as it descends causes urge to push ```

Question 34

3rd stage of labor

Answer 34

``` § 3rd stage • Begins with delivery of baby • Ends with placenta delivery • Uterus greatly reduced in size • Uterine wall reduced • Placenta is squeezed off uterine wall • Uterus contracts into hard ball & slows flow of blood from open blood vessels ```

Question 35

visual examination

Answer 35

• Check for distention or bulging of the perineum • Inside wall of the rectum may be visible as sphincter is stretched open • Perform during contraction • Crowning • Presenting part descends into pelvis • As presenting part fills the pelvic cavity, any fecal material in the mother’s rectum is expelled

Question 36

6 cardinal movement of labor

Answer 36

1. engagment 2. flexion 3. descent 4. internal rotation 5. extension 6. complete extension 7. external rotation/restitution 8. delivery of anterior shoulder 9. delivery of posterior shoulder

Question 37

management of shoulder dystocia

Answer 37

HEL(egs)P(ressure)E(nter vagina)R(oll) - episiotomy - maternal hips are flexed knees on abdomen - causing rotation of maternal pelvis and increasing size of pelvic outlet - suprapubic--pressure applied to drive fetal shoulder downward under pubic bone - insert hand to level fetal elbow, grasp forearm, sweep across chest to deliver posterior arm/shoulder - roll anterior shoulder toward fetal chest and add posterior shoulder pressure toward chest

Question 38

If unable to deliver shoulder dystocia after manual manupulation

Answer 38

- fracture fetal clavicle - symphysiotomy (divide cartilage of pubic symphysis) - cesarean section

Question 39

Cord prolapse

Answer 39

- rare in term cephalic pregnancies (0.4%) - more common in malpresentations 1. footling breech (15-18%) 2. transverse lie (up to 20%) - dx by palpation of cord on exam

Question 40

managment of cord prolapse

Answer 40

- manual replacement - mom onO2 - trendelenberg and or left lateral decubitus - push presenting part off cord - immediate C-section

Question 41

postpartum hemorrhage

Answer 41

``` § Blood loss greater than 500 mL after delivery § Early – 1st 24 hrs • Genital lacerations • Uterine rupture • Coagulation defects § Uterine inversion • Excessive traction on cord • Bearing down too hard during 2nd stage of labor § Uterine prolapse • Supporting structures fail • Uterus falls out of vagina ```

Question 42

uterine atony

Answer 42

``` § Uterine atony • Uterus fails to contract • Massive bleeding from the vagina • Signs of shock quickly follow • Uterus poorly defined, soft, boggy mass • Often above the level of the umbilicus • Uterus should be massaged until it is firm and hard • If bleeding is severe, treat for shock ```

Question 43

Late postpartum hemorrhage

Answer 43

``` § Late postpartum hemorrhage • 6 to 10 days later • Retained placental tissue • Infection • Coital (sexual) trauma • Rupture of episiotomy wound ``` ``` § May be able to control bleeding: • Uterine massage • Direct pressure with sanitary pad • Do not place packing or dressings inside the vagina ```