Vol.5-Ch.2 "Obstetrics"

Question 1

What is the time frame of the “prenatal period”?

Answer 1

From conception to delivery of fetus

Question 2

What happens to the ovum after release and fertilization of spermatozoa but before implantation?

Answer 2

Once fertilized with a spermatozoa in the distal third of the fallopian tube, it immediately begins cellular division and becomes a BLASTOCYST (hollow ball of cells). It is this blastocyst that implants in the endometrium of the uterus that has bee prepared for implantation by the released progesterone

Question 3

At what week of pregnancy does the Placenta usually develop?

What are the major roles of the placenta? (x6)

Answer 3

The placenta (organ of pregnancy) is developed around 3 weeks after fertilization at the point that the blastocyst implanted.

The major functions include:

• transfers heat
• exchanges O2 and CO2
• delivers nutrients (glucose, potassium, sodium, chloride
• Carries waste away such as uric acid, urea, and creatinine
• Acts as endocrine gland, secreting needed hormones for pregnancy including estrogen and progesterone
• Protective barrier from harmful substances ingested by mother

Question 4

How many arteries and veins does the umbilical cord have?

Which supplies O2 and which takes away CO2?

Answer 4

The umbilical cord has 2 arteries and 1 vein

The arteries take away CO2
The veins bring O2
Opposite as normal

Question 5

What is the actual term for when a women’s water breaks?

Answer 5

Rupture of the Membranes (ROM)

Question 6

What are some changes in the REPRODUCTIVE system during pregnancy?

Answer 6

A MUCUS PLUG forms in the cervix to protect the baby from infection. It will be expelled during the dilation phase and before the actual delivery.

1/6th or about 16% of total maternal blood volume is found in the vascular system of the UTERUS during pregnancy. This is why vaginal bleeds of a pregnant woman can be so dangerous for mother and fetus!!

Question 7

What are some changes to the maternal RESPIRATORY system during pregnancy?

Answer 7

O2 demand increases!

Progesterone responds to this need by decreasing airway resistance, which yields an increased 40% tidal volume and a 20% increase in O2 consumption

Question 8

What are some CARDIOVASCULAR changes that occur in a pregnant patient? (8x) (Really do first 6 hear, the last 2 will come up later)

Answer 8

• Increased Cardiac Output by 30-50% (6-7Lpm)
• Increased HR of around 10-15bpm
• Total blood volume increases 45%
• Systemic Vascular Resistance decreases
• Both RBCs and plasma increase but plasma increases MORE, causing a relative anemia. This is why women take IRON SUPPLAMENTS to increase the O2 carrying ability of the RBCs they have
• Because of the increased blood volume, a pregnant pt can lose about 30-35% of their blood with NO CHANGE IN VITAL SIGNS
• In later terms the fetus can press on the Inferior vena Cava or possibly the abdominal aorta, causing decreased Venous Return to the Right Atrium. This is called SUPINE HYPOTENSIVE SYNDROME
• It is possible that the fetus will also press on the pelvic or femoral vessels causing impaired venous return from the legs and venous stasis leading to varicose veins, dependent edema, and postural hypotension (probably also DVT)

Question 9

What are some changes in the GI system during pregnancy?

Answer 9

• Nausea and vomiting are normal in first trimester secondary to hormonal changes and changes in carbohydrate requirements
• Peristalsis is slowed so gastric emptying is delayed causing bloating or constipation
• They are more at risk of gallstones and secondary cholecystitis because of hormones delaying the emptying of the gallbladder

Question 10

What are some changes in the URINARY system during pregnancy?

Answer 10

• Renal blood flow and filtration increase by nearly 50% in the 2nd tri and throughout pregnancy
• Since tubular reabsorption increases as well, sometimes the body cannot retain as much sugar as it needs leading to GLYCOSURIA (large amounts of sugar in the urine). This can be normal OR can be a sign of gestational diabetes.
• The bladder gets displaced anteriorly and superiorly making it more prone to rupture, and frequent urination is common due to compression by the uterus

Question 11

What causes the waddling and low back pain women experience during pregnancy?

Answer 11

Waddling is caused by loose pelvic joints secondary to hormonal influences

Low back pain occurs because of a change in the mother’s center of gravity due to anterior growth of uterus/belly

Question 12

What is the name of the time of fertilization?
What is the period of the first 14 days after fertilization called?
What is the period from day 15 to 8 weeks called?
What is the period from 8 weeks to delivery called?

Answer 12

Fertilization = CONCEPTION

Conception to first 14 days = PREEMBRYONIC STAGE

15th day to 8 weeks = EMBRYONIC STAGE

8 weeks to delivery = FETAL STAGE

Question 13

What is the medical term for the “due date”

Answer 13

the Estimated Date of Confinement (EDC) or Estimated Date of Delivery (EDD)

Question 14

How many weeks/months is each trimester? Full pregnancy?

Answer 14

Each trimester is 13weeks or 3 months

Full term is 40weeks or 9 months

Question 15

When can the sex of the infant be determined?

When can you start to hear fetal heart tones?

When can the baby be able to survive a pre-mature birth? When are the chances very good? When is the baby considered “term” or fully developed?

Answer 15

Sex determination is at 16 weeks

Fetal Heart Tones can be auscultated by 20 weeks

At 24 weeks a baby MAY survive being born prematurely

At 28 weeks a baby has VERY GOOD CHANCES of surviving being born prematurely

At the 38th week the baby is considered “term” or FULLY DEVELOPED

Question 16

When does most of the fetus’ organs develop and thus is most susceptible to the development of birth defects?

Answer 16

The FIRST TRIMESTER

Question 17

What are the 3 major differences from fetus circulation and ours that allows for the bypass/access of what respectively?

Answer 17

As the O2 rich blood comes in from the placenta and down the umbilical veins TOWARDS THE FETUS” HEART it runs through the DUCTUS VENOSUS near the liver that allows direct flow into the INFERIOR VENA CANA. From there it flows into the right atrium and into the right ventricle like normal. This O2 rich blood mixes with the Deoxy rich blood coming back in through the superior vena cava, so the blood in the right ventricle is MIXED blood.

This mixed blood is then pumped out the Right Ventricle through the pulmonic valve to the pulmonary artery which NORMALLY goes to the lungs. Instead it goes through the DUCTUS ARTERIOSUS that connects directly to the aorta to be pumped out normally. There is a second access of the O2 rich blood to the aorta found via a hole between the Right and Left Atria called the FORAMEN OVALE in which the O2 rich blood coming into the right atria is allowed to mix into the blood in the left atria and thus the left ventricle before being pumped out.

So the blood leaving the aorta is oxygenated via the O2 rich blood coming to the right atria by access from the hole between the right and left atria called the FORAMEN OVALE, and the mixed blood in the left right ventricle that pumped directly to aorta instead of lungs via that DUCTUS ARTERIOSUS

(Hint the DUCTUS VENOSUS occurs before the heart, and is where the umbilical vein with O2 rich blood is allowed access straight into the inferior vena cava (which is mixed with the normal venous return of deoxy blood from below the access point) ; and the FORMAN OVALE AND DUCTUS ARTERIOSUS are access points within the heart/aorta that allow for that O2 rich blood access to be pumped out through the aorta)

Question 18

How can a mother with pre-existing diabetes be affected by pregnancy?

Answer 18

It may cause instability due to a change in insulin requirements. It could potentially accelerate the progression of vascular disease complications of diabetes. They are at an Increased risk of PREECLAMPSIA and HYPERTENSION. The mother CANNOT be managed with oral hypoglycemic agents because it can cross the placental barrier

The infants of these mothers tend to be LARGE which can complicate delivery. These infants may also have trouble regulating temp after birth and may be hypoglycemic. They are at a HIGHER RISK OF BIRTH DEFECTS.

Question 19

Patients with poor cardiac health that get pregnant may be affected how?

Answer 19

It can cause development of CHF because of the increase in cardiac output from pregnancy

BE AWARE that it is NORMAL for a quite systolic flow murmur to develop and is not of concern alone

Question 20

What is something to consider with a mother who has pre-existing hypertension other than the fact they are going to probably be pre-eclamptic?

Answer 20

Many hypertension meds cannot be taken while pregnant so hypertension may be uncontrolled compared to normal

Question 21

What is a normal fetal heart rate range?

Answer 21

140-160bpm

Question 22

What is the preferred analgesic for a pregnant pt?

Answer 22

Nitrous Oxide if available, however other’s are still acceptable

Question 23

What is the most common cause of syncope in pregnant women?

Why are pregnant pts more likely to fall?

Answer 23

Because the gravid uterus presses on the inferior vena cava, it can frequently cause syncope by he sudden loss of venous return.

The gravid uterus changes a woman’s balance making her more susceptible to falls

Question 24

What is the most frequent nonobstetric cause of death in pregnant women?

Answer 24

Trauma

Question 25

Why should you anticipate a pregnant women with trauma to go into shock instead of waiting for S&Ss?

Answer 25

Because when there is bleeding, there will be vasoconstriction in response to a catecholamine release that in combo with the already increased cardiac output and blood volume will be able to maintain a normotensive state for the mother.
HOWEVER, this vasoconstriction will lead to a shunting from the placenta, so the fetus’ blood supply will drop 20-30% and lead to bradycardia.

Question 26

What is the primary cause of fetal mortality?

Answer 26

Maternal Mortality!

Question 27

4 major causes of vaginal bleeding during pregnancy?

Answer 27

• ABORTION (main cause):
  Expulsion of fetus before the 20wk mark, mostly due to fetal chromosomal anomalies. Normal S&Ss are abd cramping, low back pain, and bleeding/clots/tissue expulsion. Treat for shock if present and transport in position of comfort. Retain any large clots or tissues for examination at hospital. If the fetus has developed before abortion it may come out and be suspended by the umbilical cord (the placenta does not often follow in these cases) so go ahead and clamp and cut and wrap fetus in cloth.
• ECTOPIC PREGNANCY:
  S&Ss are often abd pain which starts diffuse and becomes pinpoint, this is because the fetus has outgrown the fallopian tube and ruptured it, causing bleeding into the abd space. Treat the associated signs and symptoms, pain management may be required. Transport asap as surgery will be required.
• PLACENTA PREVIA:
  Implantation of the placenta on the lower half of the uterine wall resulting in partial or complete coverage of the cervical opening. It can be complete, partial, or marginal. It typically presents after the 7th month once the lower uterus begins to contract and dilate in preparation for the onset of labor. THE HALLMARK SIGN is bright red, painless, vaginal bleeding and the usual patient is a multigravida in her third trimester. Treatment includes shock management and transport to hospital as a C-Section will be required.
• ABRUPTIO PLACENTAE:
  Is the premature separation of a normally implanted placenta from the uterine wall. PARTIAL abruptions can be marginal or central. MARGINAL abruptions are characterized by vaginal bleeding but no increase in pain. In a CENTRAL abruption the placenta separates centrally and the bleeding is trapped between the placenta and the uterine wall, or “concealed”, so there is no bleeding but there is a sudden, sharp, tearing pain and a stiff, board like abdomen. In COMPLETE abruptio there is massive vaginal bleeding and profound maternal hypotension. Treat for Shock!

Question 28

What are the 4 different types of hypertensive emergencies pregnant women face?
(There is an extra bonus for 5)

Answer 28

• PREECLAMPSIA: (most common)
  Preeclampsia is defined as an increase in systolic by 30mmHg and diastolic of 15mmHg above baseline on at least 2 occasions within 6 hours of each other. If there is no baseline, then 140/90 or higher is considered hypertensive. (REMEMBER that hypotension is normal in early and late pregnancy, so a normal 120/80 might by hypertensive if the pt had like 90/75 before at rest. Preeclampsia is normally seen in the last 10 weeks or 48hours postpartum. It can be MILD (hypertension, edema, and protein in urine) or SEVERE (BP of 160/110 or higher, generalized edema, and spiked protein in urine). It is thought to be caused by vasospasms which causes a decrease in placental blood flow.
• ECLAMPSIA:
  This is preeclampsia but with seizure activity (general tonic-clonic) that has occurred secondary to the hypertension. Pain in the upper right quadrant and visual disturbances typically are signs of an impending seizure. Risk of fetal mortality raises by 10% with each seizure.
• CHORNIC HYPERTENSION:
  is when the mother has 140/90mmHg BP preceding pregnancy, prior to the 20th week, or if it lasts more than 42 days postpartum. As a general rule, if the diastolic is above 80 during the second trimester, chronic hypertension is likely
• CHRONIC HYPERTENSION SUPERIMPOSED W/ PREECLAMPSIA:
  Self explanatory
• TRANSIENT HYPERTENSION:
  A temporary rise in BP that occurs during labor or early in postpartum and NORMALIZES WITHIN 10 DAYS

Question 29

Management of a preeclamptic or eclamptic pt?

Answer 29

Preeclamptic:
Transport in left lateral recumbent, dim lights, without lights or sirens. If the BP is severe, a diuretic may be ordered. The book says to start an IV drip of normal saline but I wouldn’t do that if they are already hypertensive

Eclamptic:
Give bolus of magnesium sulfate to control the seizures. If refractory to mag, consider diazepam or other sedative. Transport immediately

Question 30

What is gestational diabetes and how does it develope?

Answer 30

When a woman is pregnant, insulin and tissue response to insulin increases due to hormonal changes. However, in the last 20 weeks of pregnancy, the opposite occurs; insulin production and response decreases leading to a catabolic state between meals and during the night. Ketones can even be found in urine because fats are being used as the primary energy source. This is known as the Diabetogenic Effect of Pregnancy.

If pregnant pt is AMS check their blood sugar! If it is LESS THAN 60mg/dL draw a red-top tube of blood and start an IV of normal saline, then 50-100mL of 50%dextrose via IV, if the pt is alert and can swallow then give oral glucose or juices, etc. If the blood sugar is GREATER THAN 200 mg/dL then draw a red-top tube of blood and admin 1-2L of 0.9% sodium chloride

Question 31

What is the main difference between actual contractions of labor and Braxton-Hicks contractions.

Answer 31

The biggest difference is that actually contractions of labor will cause dilation and effacement (thinning and shortening) of the cervix where as Braxton-Hicks contractions do not.

Other differences is that Braxton-Hicks can start as early as the 13th week and may be painless, but they will grow in intensity and frequency as the EDC approaches. They are thought to be conditioning for the birthing process and enhance placental circulation. Actual contractions of labor will be regular, firm, and quite painful.

Question 32

What is the primary neonatal health problem?

Answer 32

Preterm delivery (any delivery before the 38th week when the fetus is considered “term” or fully developed).

The greatest concern in preterm labor is that the lungs may not be fully developed. This is also why the 28th week is such a mile stone for high survivability rate because it marks when the surfactant needed for normal lung function is formed.

If you have a pt that is less that 38 weeks pregnant and had RUPTURE OF THE MEMBRANE then that is a CONFIRMATION of preterm labor.

If the fetus is preterm then labor should be STOPPED if possible, this process is called TOCOLYSIS and is normal in obstetrics but not the field.

Question 33

What are the 3 general ways to approach Tocolysis (process of stopping labor)

Answer 33

• Sedate the Patient:
  Use narcotics or barbiturates to allow rest, as rest will often stop contractions
• Admin a Fluid Bolus IV:
  Giving 1L of fluid will cause a stop of ADH secretion from the posterior pituitary gland. Since ADH and Oxytocin (hormone of labor) are both secreted from the Post Pituitary and have a similar chemical makeup, any inhibition of ADH will also inhibit Oxytocin release
• ONLY IF THE OTHER METHODS FAIL can you move to the third option of giving magnesium sulfate or a beta agonist to reduce the uterine smooth muscle contraction. This is NOT typical practice on an ambulance.

Question 34

What is Labor?

Just prior to the onset of true labor what occurs?

Answer 34

It is the process of childbirth in which physiologic and mechanical changes expel the baby, placenta, and amniotic sac through the birth canal.

Just prior to the onset of true labor the head of the fetus descends in o the body pelvis area.

Question 35

What are 2 signs that labor is imminent?

Answer 35

Expulsion of the mucus plug or Rupture of the Membranes

If either occurs, labor should begin within 12-24 hours. If it does not than labor may need to be induced as infections can start to occur.

Question 36

How should you gauge the time between contractions?

What are 2 important things to watch for during labor?

Answer 36

From the beginning of one to the beginning of the next. (NOT from the end of one to the beginning of the next)

• note if the uterus relaxes completely between contractions
• keep an eye on fetal heart rate during labor, during contractions the fetus’ heart can become bradycardic but should return to normal after the contraction ends (120-160bpm); if it does not then it could be a sign the fetus is in distress.

Question 37

What are the 3 stages of Labor?

Answer 37

• Stage One (Dilation Stage) :
  Begins with the onset of True Labor Contractions and ends with the complete dilation and effacement of the cervix. Dilation should be around 10cm which may take 8-10 hours for nullipara (first) or 5-7 for multipara. Effacement is the process of cervix change from thick and long to short and paper thin and usually starts days before active labor. Contractions in this stage start out lasting around 15-20 seconds and about 10-20 minutes apart but end around 60 seconds of duration separated by about 2-3 minutes
• Stage 2 (Expulsion Stage) :
  Begins with complete dilation of the cervix and ends with the delivery of the fetus. This normally takes 50-60 minutes for nullipara or 25-30 for multipara. The hallmark sign of the beginning of the second stage is the urge to bare down to push. Normal delivery of the baby is in the VERTEX position aka head first and face down
• Stage 3 (Placental Stage) :
  Begins just after the birth of the baby and ends after the delivery of the placenta. This usually takes 5-20 minutes. NO need to delay transport waiting for this. Signs that the placenta had separated from the uterus and is on its way is if there is a gush of blood, change in uterus, or length of the umbilical cord protruding from the vagina. Often there is continued vaginal discharge called Iochia that contains blood, mucus, and placental tissue that may continue for 4-6 weeks.

Question 38

What are 5 things to consider when determining whether to deliver on scene or transport to the hospital?

Answer 38

• Number of previous pregnancies
• Length of labor of the previous pregnancies
• Frequency of contractions
• Maternal urge to push
• Presence of crowning

Question 39

What is the only absolute contraindication for a C-section aka VBAC?

Answer 39

A classic vertical uterine incision

Most C-sections aka VBAC are done using a low transverse uterine incision

Question 40

What are 4 things that would make you want to transport instead of try to deliver on scene?

Answer 40

• Prolonged rupture of membranes (>24hrs; this leads to infections)
• Abnormal presentation such as a breech
• Prolapsed cord
• Fetal Distress (seen by bradycardia or MECONIUM STAINING - the presence of meconium, the first fetal stools, in the amniotic fluid)

Question 41

Steps to field delivery of Fetus

Answer 41

• Set up delivery area in a private place, place a towel under the buttocks, another below the vagina, and another draped over the lower abdomen. Gloves, gown, and mask should be used if available.
• NOTE: Monitor the fetal pulse frequently; if it drops BELOW 90bpm, initiate rapid transport
• Coach mother to breath deep between contractions and PUSH WITH contractions. NOTE: If the baby does not deliver after 20 minutes of contractions every 2-3 minutes then Transport Immediately
• As the head crowns, control the head and perineum with gentle pressure, this insures the baby’s head does not come out to quick and prevents perineum tearing.
• As the head delivers, support it as it comes out and TURNS? and if it is still in the amniotic sac, TEAR the sac to allow the baby to breath. It is no longer recommended that you suction the nasopharynx without obvious obstruction. Also, gently slide your finger around it’s head and neck to ensure the umbilical cord is not wrapped around it’s neck.
• IF THE UMBILICAL CORD IS AROUND NECK, then gently try to lift it over the shoulder, without tearing! If you cannot do this, then put clamps 2 inches apart and cut between them.
• Once the head is safely out of the vagina, Gently guide the HEAD DOWN to allow delivery of the upper shoulder. Then guide the BODY UP to allow delivery of the lower shoulder. DO NOT PULL!!
• Once the shoulders are out the rest follows quickly, next to cut the cord while supporting the body, place the first clamp 10 CENTIMETERS FROM THE BABY, and then another 5 CENTIMETERS ABOVE THE FIRST CLAMP, then cut between them. NOTE: keep the baby at the level of the vagina to prevent hypo or hyper transfusion of blood until the cord is cut. ALSO do not “milk” the cord!
• Lastly suction the airways AS NEEDED, dry the baby thoroughly, and wrap in warm and dry blankets or towels and position on his side. RECORD THE TIME OF BIRTH

Question 42

Steps after Fetus and Placenta are delivered

Answer 42

• After the baby is born, the placenta should come out on it’s own next, DO NOT PULL on the umbilical cord. Once the placenta has been delivered PLACE IT IN A PLASTIC BIOHAZARD BAG and deliver it to the hospital for examination.
• Once everything has been delivered, the next goal is to control bleeding. Inspect the perineum of tears and if present, apply direct pressure.
• Contractions will continue after full delivery to help naturally control bleeding, the help facilitate this you can massage the uterus by placing hands on the pubic symphysis and the uterine fundus. You can also place the baby on the mothers breast which stimulates contractions.
• ONLY AFTER the placenta comes out can a paramedic consider giving the mother Oxytocin (Pitocin) to medically facilitate contractions.

Question 43

Immediate Neonate care includes: ?

Answer 43

• Maintain Warmth:
  this is done by rapidly drying the baby and placing a warm, dry blanket or towel around baby (do not wrap baby in same blanket you dry with as it will be wet)
• Clearing the Airways:
  Do not suction immediately unless you observe airway obstruction. Typically if drying does not stimulate the baby you can stimulate by FLICKING the soles of the feet or RUBBING the BACK in a gentle circular motion. This should cause the baby to “pink up”. Remember any acrocyanosis is NORMAL. If stimulation does not stimulate breathing then assist with a bag valve mask on ROOM AIR initially, upgrade to O2 as needed
• Assign an APGAR score at 1 and 5 minutes post birth (details of APGAR on separate card)

Question 44

What is Acrocyanosis?

Answer 44

It is when a neonate’s extremities remain a dusky color for an extended period of time, even if properly stimulated. THIS IS NORMAL and may last for the first few hours after birth

Question 45

What is the normal heart rate and respiratory rate of a Neonate?

Answer 45

Heart Rate = 100-180bpm

Resp Rate = 30-60

Question 46

What is APGAR and how is it scored?

Answer 46

APPEARANCE (skin color):
2 - All Pink
1 - Body pink, extremities blue
0 - All blue/pale

PULSE:
2 - 100bpm or more
1 - Below 100bpm
0 - Absent

GRIMACE (irritability):
2 - Cough, Sneeze, Cry
1 - Grimace
0 - No Response

Activity:
2 - Active Motion
1 - Some Flexion
0 - Limp

Respiratory Effort:
2 - Strong Cry
1 - Slow and Irregular
0 - Absent

This measures the neonates status of vital functions

Question 47

What care is needed for a neonate with an APGAR score of:
7-10
4-6
0-3

Answer 47

7-10APGAR: Needs only routine care

4-6APGAR: Moderately Depressed and need O2 and stimulation to breath

0-3APGAR: Severely Depressed and require immediate ventilatory and circulatory assistance

Question 48

If the neonate’s heart rate is below ____ and is not breathing then do what? (we go more in depth with this in the “Neonatology” chapter)

Answer 48

If the heart rate is below 60bpm and is not responding to ventilations then begin chest compressions.

Try to gain IV access for medication administration. The MOST LOGICAL, IDEAL, & EASIEST IV ACCESS is through the umbilical vein. If this is not an option though IO may be the next easiest but look for a peripheral vein before going IO.

Question 49

What is a Breech Presentation and how do you manage it?

Answer 49

BREECH PRESENTATION:
- This is when the butt or BOTH feet present first instead of the normal Vertex Position (head first, face down). This presents increased risk of damage to the mother and risk of injury to Neonate.

• Management is usually a C-Section in the hospital but if in the field you can aid in the passing of the body if it comes out itself by supporting it, DO NOT PULL LEGS. As the head passes apply upward pressure until the mouth appears over the perineum.
• If the HEAD DOES NOT DELIVER, and the baby begins to breath spontaneously with the face against the vaginal wall, you can place two fingers with the palm facing the infants face and form a “V” shape around the infants nose and push the vaginal wall away from the infants face to allow access to air.
• If the SHOULDERS DO NOT DELIVER you can, extract 4-6 inches of the umbilical cord, rotate the fetus so that the shoulders are in a posterior/anterior position and then gently guide the infant up and then down to deliver each shoulder. Take care not to compress the cord while doing so

Question 50

What is a Prolapsed Cord and how do you manage this??

Answer 50

It is when the cord precedes the fetal presentation.
When this occurs, The cord can be compressed between the pony pelvis and the fetus. If this occurs take 2 fingers and gently lift the fetus off the cord, while checking for any pulsating. Transport immediately while holding the fetus off the cord and with the mother in a Trendelenburg or knee-to-chest position. DO NOT attempt delivery, pull cord, or push cord back into vagina!! If you can, try to place a wet dressing over the exposed cord.

Question 51

What is a Limb Presentation and how do you manage this?

Answer 51

This is seen when a baby is lying transverse in the uterus and an arm or leg presents first.
If this occurs, DO NOT touch the limb (this may stimulate fetus to breath while still in amniotic fluid), attempt delivery, or push limb back into vagina. A C-section is necessary to transport immediately! And place the mother in a Trendelenburg or knee-to-chest position.

Question 52

Why is it different if the baby is face up or face down?

What is the official term for “sunny side up”?

Answer 52

Face Up = OCCIPUT POSTERIOR POSITION

When the baby is in occiput posterior position it delays passage through the pelvis because when delivery is normal and the baby is face down, the natural extension of the neck helps the fetus move easier through the pelvis. This may require forceps or C-Section usage at a hospital

Question 53

What are some things to note about a multiple birth pregnancy?

Answer 53

• You will need additional people to help
• The babies are typically smaller and thus heat retention is more important
• There may be 1 or more placentas but after one baby is born still clamp that cord as normal before the next delivery
• Typically one baby is born in the Vertex position and the other is breech
• These babies are typically born premature, and labor begins earlier from delivery than normal

Question 54

What is Cephalopelvic Disproportion?

Answer 54

This is when the infant’s head is too big to pass through the maternal pelvis easily. The only treatment for this is a C-section

Question 55

What is a Precipitous Delivery?

Answer 55

A delivery that occurs after less than 3 hours of labor

Question 56

What is Shoulder Dystocia?

Answer 56

When the infants shoulders are larger than the head. Typically with this the head will deliver normal and then get retracted back into the perineum because the shoulders are caught.

To manage this you can attempt a McRobert’s Maneuver that is have the mother put her butt off the end of the bed, then have her flex her thighs upwards to facilitate delivery and apply firm pressure with an open hand above the pubic symphysis. If this does not help she will need a C-Section and you need to transport immediately while supporting the head that is delivered.

Question 57

What is Meconium Staining?

Answer 57

Occurs when the fetus passes feces into the amniotic fluid. This is always indicative of a fetal hypoxic incident. Hypoxia causes an increase in fetal peristalsis and relaxation of the anal sphincter. This will be obviously observable as the color of the amniotic fluid (normally clear or straw colored) will be a light yellow-green or dark green (the darker the color the worse)

The only management required is to properly suction the airway as needed and report to the hospital of the occurrence

Question 58

What are 4 maternal complications that can occur for or after delivery?

Answer 58

• POSTPARTUM HEMORRHAGE:
  This is the loss of more than 500mL of blood immediately following delivery. The most common cause is Uterine Atony aka the lack of uterine muscle tone. The uterus will often feel boggy and soft, and blood flow will be an obvious steady free flow. Management includes admin of IV fluids and oxytocin as well as a fundal massage
• UTERINE RUPTURE:
  This is when the uterus ruptures or tears before or during pregnancy. Before is usually from trauma but during is usually from prolonged uterine contractions or a surgically scarred uterus. Typically upon rupture the pt will feel severe pain, contractions will stop, there will be shock without external hemorrhaging, no fetal heart tones, tender and rigid abdomen, and mortality for mother and fetus is high. Manage shock and transport rapidly.
• UTERINE INVERSION:
  This is when the uterus turns inside out and protrudes through the cervix. This will tear the supporting ligaments and blood vessels causing profound shock. Typically 800-1000mL of blood is lost. This typically occurs secondary to pulling on the umbilical cord or attempts to express the placenta while the uterus is relaxed. To manage this treat shock and give 1 ATTEMPT to replace the uterus by placing a hand on the fundus and and push towards the vagina. If unsuccessful, place wet towels over it and transport.
• PULMONARY EMBOLISM:
  This is one of the most common causes of maternal death and occurs more often after a C-section than a live birth

Question 59

Important things to consider in a cardiac arrest pregnant patient

Answer 59

• You should try to estimate the gestational age. This can be done by measuring the fundal height from the pubic symphysis but generally if the fundus is:
  a) Palpable at the pubic symphysis then its at least at the 12 week mark
  b) Palpable at the umbilicus then its at least at the 20 week mark
  c) Palpable at the xiphoid then its at least at the 36 week mark
• When doing compressions the uterus can cause AORTOCAVAL COMPRESSION, aka compress the aorta and vena cavas. To avoid this you should use MANUAL LATERAL UTERINE DISPLACEMENT (LUD) in which you move the uterus UP AND LEFT during compression.
• Since maternal O2 reserves are lower than normal, early oxygenation is even more important than usual
• Other than that everything else should be done as normal!! DRUGS AND SHOCKS ARE STILL SAFE and should be used and not altered