1. LYSTRA WILSON-CELESTINE, FACOG May 21th 2015
EMS OBGYN OVERVIEW
LYSTRA WILSON-CELESTINE, FACOG
May 21th 2015

2. OBJECTIVES Review female anatomy and reproductive system
Normal pregnancy, labor and delivery
Assessing a pregnant patient
Common complications and emergencies of pregnancy
Newborn care
Review of case scenarios

3. Definition of Terms Gravity: # of pregnancies
Parity: # of pregnancies >20wk
Nulliparous: never pregnant
Primagravid: first pregnancy
Gravity- this includes ectopic and miscarriages, abortion
In parity a twin pregnancy is counted as a single pregnancy

4. Definition of Terms
Presentation: leading part in birth canal- crown, rump, face, arm.
Term : 37 to 42wks.
Preterm : <37wks
Post term:>42wks
Abortus: Fetus /embryo delivered <20wk/500gm

5. External Genitalia

6. Pelvic Anatomy

7. Reproductive Organs

8. Physiology of Pregnancy
Genital Tract
Vagina, perineum:
Increased vascularity, hyperemia, edema
Increased secretions (thick white discharge)
Acidic pH( 3.5-6)
Increased vaginal wall length
Chadwick’s sign- violet color of vagina/vulva
For a successful pregnancy major adaptions are required in maternal anatomy, physiology and metabolism. It is necessary to understand the normal changes to recognize the abnormal.

9. Normal cervix

10. Chadwick’s sign and leucorrhea

11. Chadwick sign- pregnant

12. Physiology of Pregnancy Uterus
fold increase in size
Wt. at term +/- 1100gm
Out of pelvis by end of 12th wk.
Dextrorotated
Blood flow increases from 100 to 650ml/min
Limited auto regulation
Increase in size due to stretching and hypertrophy of muscle cells caused by estrogen and POC venous compression, supine hypotension,
Uterine artery dilates due to hormone effect leading to decreased resistance to flow.
Vessels are maximally dilated to improve blood flow but when maternal cardiac output declined blood shifts from uteroplacental bed to maternal brain, kidney and heart.

13. Physiology of Pregnancy Uterus
Limited Auto regulation
Maximum uterine vessel dilation leave little auto regulation to improve flow during perfusion pressure changes
Decreased maternal cardiac output blood flow shift away from placenta to maternal brain, kidney and heart.
Uterine Hypertrophy
Venous compression fall in venous return, fall in cardiac output
Compensation: Supine hypotension syndrome, nausea, dizziness, syncope, relief by position change
Increased size due to stretching and hypertrophy of muscles caused by estrogen and POC

15. Physiology of Pregnancy Cervix
Thickened mucus
Chadwick sign
Eversion of columnar cervical glands

16. Physiology of Pregnancy Ovaries
Suspended follicular maturation
Enlarged ovarian veins
Single corpus luteum
Functional 4-5wks post ovulation
Produces progesterone, relaxin

17. Physiology of Pregnancy Skin
Vascular
Spider angiomas
Palmar erythema- also seen thyroid disease, lung CA or inherited
Striae gravidarum
Genetic disposition

18. Palmar erythema

20. Spider Angioma

21. Striae gravidarum

22. Physiology of Pregnancy Skin
Increased pigmentations due to estrogen, progesterone, melanocytes simulating hormones
Linea negra
Chloasma/Melasma gravidarum

23. Linear Negra

24. Molasma Gravidarum

25. Physiology of Pregnancy Breast
Tender/tingling sensation in early preg
Nipple enlarges, broader areolae with increased pigmentation
Increase size from ductal growth and alveolar hyperplasia
Colostrum production

26. Physiology of Pregnancy Musculoskeletal
Lumbra lordosis low back pain
Relaxation of pubic symphysis and sacroiliac joints
Relaxed muscles leading to hernia and easily strained muscles
All compounded by weight gain.

27. Lordosis of pregnancy

29. Physiology of Pregnancy Hematologic
50% increases in blood volume
Plasma volume increases 50-70%; starts at 6wks
RBC mass increase 20-35%: starts at 12wk
Physiologic anemia
Hemodilutional
Anemia nadirs at 30-34wks

30. Physiology of Pregnancy Hematology
Iron Deficiency Anemia
Increased iron requirements, supplements recommended
term Hgb <10mg/dL due to deficiency rather than hemodilution
Immune changes
WBC increases to in 3rd TM
Plt decrease slightly

31. Physiology of Pregnancy Hematology
Coagulation
Fibrinogen increases 50%
Changes in clotting factors and regulatory protein
Cardiac output
Begins to increase by 5th wk
Peaks at 20-24wks
Rises by 40% by 20-24wks
Overall 50% increase

32. Physiology of Pregnancy Hematology
Initially increase in heart rate
Reduced systemic vascular resistance
CXR: displaced heart to left upward and pericardial effusion

33. Physiology of Pregnancy Test Interpretation
BP: SBP increases by 5-10mmHg; DBP by mmHg (before 24wks).
Each contraction pushes ml from uterus to circulation Rise in arterial BP 10mmHg during Ctx.

34. Physiology of Pregnancy Respiratory
Estrogen hyperemic, edematous nasopharynx and increased mucous secretions. Symptoms: stuffiness, epistaxis, chronic cold.
 chest circum. and transverse diameter; Diaphragm pushed up 4cm Changes in lung volumes and pulmonary function test.
Oxygen consumption increases 15-20%
BOTTOM LINE
State of hyperventilation with chronic respiratory alkalosis

35. Physiology of Pregnancy Urinary
Mechanical
Ureteric obstruction from uterus
Incomplete bladder empting
Vesicoureteral reflux
Physiology
75%  renal blood flow with increase in GFR 50%
Multiple trips to bathroom
Glucosuria, Proteinuria

36. Physiology of Pregnancy Gastrointestinal
Increased appetite (300kcal/d)
Ptyalism (1-2L/d) spitting
Gingivitis
Lower tone of Gastroesophageal sphincterreflux
Delay gastric emptying (60% of meal emptied in 90mins for non-pregnant; doubled time for pregnant)

37. Physiology of Pregnancy Gastrointestinal
Increased small bowel transit time 58 vs 52hrs
Stomach and intestinal displacement appendix at right flank
Constipation/Hemorrhoids
Gallbladder changes increased risk of stones

38. Normal Pregnancy Events
1st Trimester (LMP to 13wks)
Nausea/Vomiting, fatigue, Food aversion or cravings, spotting, breast tenderness, increased sex drive
Gain about 5-8lbs
Complications- Miscarriage, Ectopic, blighted ovum

39. Normal Pregnancy Events
2nd Trimester (13-26wks)
Feeling of well being, less fatigue.
Round ligament pain, bladder pressure, round ligament pain, Braxton hicks
Complications- fetal loss is minimal but can seen with labor, incompetent cervix, intrauterine death.

40. Normal Pregnancy Events
3rd Trimester (26wks to delivery)
Feeling uncomfortable; pelvic/back pain and pressure
Lower extremities swelling, varicosities, engagement, contractions,.
Wt gain 1lbs/wk
Complications: Rupture membranes, preterm labor, pregnancy induced hypertension, Urinary tract infection, Gestational diabetes

41. Complications of Pregnancy
Vaginal bleeding
Spontaneous Miscarriage
Ectopic Pregnancy
Premature rupture of membranes with cord prolapse
Pre eclampsia/Eclampsia
Placental Previa

42. Complications of Pregnancy
Medical/surgical eg diabetes, ruptured appendix
Abruptio Placenta
Breech presentation and delivery
Meconium Stained fluid
Abnormal labor pattern
Stressed Newborn

43. Labor Clinical diagnosis Onset of regular rhythmic contractions
Progressive cervical dilation and effacement
3 stages

44. Stages of Labor
Stage 1
Interval between labor onset and full cervical dilation
Latent phase- period btw labor onset to start of rapid change of cervical dilation
Active phase- period from 6cm to 10cm

45. Stages of Labor
Stage 2
Interval btw full dilation (10cm) to delivery of infant
Nulliparous- push for max of 2hr without regional anesthesia(3hr with)
Multiparous- push for max 1hr without anesthesia (2hr with)

46. Stages of Labor
Stage 3
Refers to delivery of placenta and fetal membranes
Make take up to 30mins
What are the active interventions if >30mins?

47. Cardinal Movement of Labor
Engagement- passage to widest diameter of presenting part below plan of pelvic inlet
Descent- downward passage of presenting part through pelvis
Flexion- passive flexion of head on to chest

48. Cardinal Movements of Labor
Internal Rotation- vertex moves from transverse to anteroposterior position
Extension – fetus head is at level of introitus; base of occiput is at inferior margin of pubic symphysis
External Rotation- or restitution- return of head to correct anatomical position- LOA or ROA
Explusion- delivery of rest of fetus

49. Demonstration of Delivery Method.
xCo

50. Field Obstetric Assessment
Determine if delivery is imminent
Remain calm
Ask few questions
Closed ended
Simple answers
Perform visual exam (with permission)
Evaluate vitals

51. Obstetrics Assessment
Things you want to know
Due date
Number of pregnancies delivered in past
Length of labor in past
Is there vaginal bleeding or did she break her water
Is there a feelings to have a bowel movement

52. Obstetrics Assessment
If delivery is imminent- What are the signs?
Crowning or bulging
She screams “I need to take a dump “or “its coming” or “I have to push”
What to do!
Remain calm, place patient supine in safe location.
Disrobe undergarment – have pt/husband/ SO do it.
Visual check of perineum- blood loss, fetal parts, bag
Abdominal palpation for contractions-duration, interval

53. Obstetrics Assessment Field Delivery
Anticipate exposure of large amount of blood and body fluids
Full personal protection is recommended
Don’t assume absence or presence of disease by appearance of patient or situation.

54. Sterile OB Kit Content Sterile exam gloves Disposable scalpel
Maternity pad
Plastic lined under pad
Receiving blanket
Disposable towels
Gauze sponges
Disposable bulb syringe
Disposable plastic apron
Plastic bag to hold placenta
Twist ties
O.B. towelettes
Umbilical cord clamp

55. Obstetrics Assessment Field Delivery
You are ready for a delivery!!!

56. Crowning/Extension

57. External Rotation

58. External Rotation

59. Delivery of Anterior Shoulder

60. Delivery of Posterior Shoulder

61. Double cord clamping and cutting

62. Case Scenario #1

63. Case Scenario #1 Post partum hemorrhage risk factors:
Grand multiparous, rapid labor, prolonged labor, augmented labor
History of postpartum hemorrhage, episiotomy, especially mediolateral, preeclampsia,
Overdistended uterus (macrosomia, twins, hydramnios), operative delivery, Asian or Hispanic ethnicity, chorioamnionitis

64. Case Scenario #2

65. Case Scenario #2 Cord Prolapse True emergency
Need to release pressure of head against cord
Sterile vaginal exam check for cord pulsation and push up on vertex.
Keep hand in vagina until OB team takes over.
Emergency cesarean section with general anesthesia is fastest way to deliver.

66. Case Scenario #2

67. Case Scenario #3

68. Case Scenario #3 Abruptio Placenta
Premature separation of normal placenta from uterine wall secondary to decidual bleeding.
1/86 to 1/206 cases.
Risks factors:
Hypertensive disease,
Advanced maternal age and parity
Drug use (eg smoking, cocaine)
Trauma
Uterine anomalies eg fibroids
Sudden decompression eg ROM

69. Placental Abruption

70. Case Scenario #3 Abruptio Placenta
Classic Signs: vaginal bleeding, abdominal pain, uterine contractions and tenderness
Abruption can be concealed with no evidence of vaginal bleeding (10-20%)
Size of hemorrhage predictive of fetal survival >60ml associated with >50% fetal mortality.

71. Case Scenario #4

72. Case Scenario #4 Neonatal Resuscitation
Assessing a Newborn- 3 questions!!
Is the baby term?
Is the baby breathing or crying?
Is the baby moving with good tone or is it flaccid?
If YES to all, then
Clamp and cut cord 7-8 inches from insertion site
Place baby with mom
Provide warmth, dry baby’s skin
Record APGAR

73. Case Scenario #4

74. Case Scenario #4 Neonatal Resuscitation
If NO to any of the 3 questions, then
Provide warmth
Clear airways if necessary
Stimulate baby
Check HR: if <100- assist ventilation with bag valve mask
Check breathing: if labored or cyanotic- clear airway
Re evaluate HR and breathing after intervention

75. Case Scenario #4 Neonatal Resuscitation If HR <60 start compression
Revaluate HR and breathing. If no change consider intubation (hopefully you are in the ER dept)
Establish access: umbilical vessels, IV, IO
Medication use if condition deteriorates
Consider possible narcotic use in mom- narcan for reversal.
Pneumothorax, anomalies, cardiac or respiratory defects, blood sugar etc.

76. Case Scenario #5

77. Case Scenario #5 Ectopic pregnancy
Implantation of fertilized ovum outside uterine cavity
2% of all pregnancies in USA
Most common cause of maternal mortality in 1st trimester

78. Case Scenario #5 Ectopic Pregnancy- Risk Factors Prior ectopic (15-5%)
Tubal surgery (15-20%)
Tubal pathology (90%)
PID history (6-9%)
Infertility (5%)
Sterilization (33%)

79. Case Scenario #5 Ectopic pregnancy Locations: Tubal 96% Ovarian <1%
Cervical<1%
Abdominal 1.3%

81. Case Scenario #5 Ectopic Pregnancy Signs Abdominal tenderness 91%
1st TM bleeding 79%
Tachycardia, low grade fever
Cervical motion tenderness
Tender pelvic or adnexal mass
Chadwick sign
Hypoactive bowel sound

82. Case Scenario #5 Ectopic Pregnancy- Symptoms Differential Diagnosis
Onset about 6-7wks after LMP
Pelvic pain
Vaginal bleeding
N/V/D and dizziness
Differential Diagnosis
Appendicitis
Threatened abortion
Ruptured ovarian cyst

83. Case Scenario #5 Ectopic pregnancy- Differential Diagnosis Diagnosis
PID
Endometritis
Kidney stones
Normal pregnancy
UTI
Diagnosis
Beta HCG levels
Ultrasound

84. Case Scenario #5 Ectopic Pregnancy Treatment Expectant management
Medical- Methotrexate( anti metabolite)
Surgical

85. Case Scenario #6

86. Case Scenario #6 Preeclampsia- eclampsia
Form of hypertensive pregnancy specific disorder that occurs after 20wks
Characterized by vasospasm, coagulation system activation, hyperreflexia
Multitude of Symptoms
Categorized: mild vs. severe preeclampsia

87. Case Scenario #6 Preeclampsia-eclampsia Mild pre eclampsia
BP >140/90
+1 urine dip protein or >300mg on 24hrs
Severe Preeclampsia
BP >160/110
Proteinuria >5g or 3-4+ urine dip
Cerebral and visual disturbance
Epigastric pain
Pulmonary Edema

88. Case Scenario #6 Preeclampsia-eclampsia
Elevated liver enzymes
HELLP
Cause unknown; possible abnormal placentation or endothelial activation
Prevention – no proven therapy
Low ASA
Calcium
Antioxidant eg Vit A

89. Case Scenario #6 Preeclampsia-eclampsia Treatment
Delivery is ONLY known treatment
Vaginal delivery unless otherwise indicated
Delivery based on gestational age and severity of disease.
Treatment
Eclamptic Seizure prophylaxis/treatment- Magnesium sulfate IV
Antihypertensive therapy SBP > DBP >110

90. Case Scenario #6 Preeclampsia-eclampsia Treatment Postpartum
Monitor coagulation factors and LFTs
Aggressive fluid management, risk of pulmonary edema
Monitor urine output
Postpartum
Continue Mg SO4 for 24hrs
BP control, 40% recurrence rate.