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Obstetrics
EMS Professions
Temple College
Pregnancies
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Most are uncomplicated
Complications can arise from:
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Eclampsia/Pre-eclampsia
Diabetes
Hypotension/Hypertension
Cardiac disorders
Abortion
Trauma
Placenta abnormalities
Childbirth
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Involves Labor and Delivery
Natural process, often only requiring
basic assistance
Childbirth
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You have at least two patients!
Childbirth
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Complications can occur
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Breech/limb presentation
Multiple Births
Umbilical cord problems
Disproportion
Excessive bleeding
Pulmonary embolism
Neonate requiring resuscitation
Preterm labor
Female Reproductive System
Female Reproductive System
Anatomy/Physiology
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Ovulation
Fertilization
Implantation
Anatomy/Physiology
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Placenta
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Transfer of gases
Transport of nutrients
Excretion of wastes
Hormone production
Protection
Anatomy/Physiology
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Umbilical cord
• Connects placenta to fetus
• Two arteries
• One vein
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Amniotic Sac
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Membrane surrounding fetus
Fluid originates from feral sources
500 - 1000 cc (after 20 weeks)
Rupture produces watery discharge
Terminology
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Antepartum - before delivery
Postpartum - after delivery
Prenatal - occurring before the birth
Natal - connected with birth
Gravida - number of pregnancies
Para - number of pregnancies carried to full term
Abortion - number of pregnancies that ended before full
term
Primigravida - woman who is pregnant for the
first time
Primipara - woman who has given birth to her first child
Multiparous - woman who has given birth multiple times
Gestation - period of time for intrauterine fetal development
Fetal Growth Process
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End of third month
• Sex may be distinguished
• Heart is beating
• Every structure found at birth is present
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End of fifth month
• Fetal heart tones can be detected
• Fetal movement may be felt by mother
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End of sixth month
• May be capable to survive if born prematurely
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Middle of tenth month
• Considered to have reached full term
• Expected date of confinement (EDC)
Ectopic Pregnancy
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Pathophysiology
• Outside uterine cavity
– 95% Fallopian tubes
• 1 in every 200 pregnancies
• Most are symptomatic
• Predisposing factors
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Tubal infections
Previous tubal surgery
IUD use
previous ectopic pregnancy
Ectopic Pregnancy
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History
• Missed period
• Other signs of early pregnancy
• Vaginal bleeding 6 -8 weeks after last
period
– Upon rupture, bleeding may be excessive
Ectopic Pregnancy
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History
• Lower abdominal pain
– May be:
• Sharp or dull
• Constant or intermittent
• Diffuse or localized
– May be referred to shoulder
Ectopic Pregnancy
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Physical Exam
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S/S of hypovolemic shock
Positive tilt test
Tender lower abdomen
Palpable mass may be present
Ectopic Pregnancy
Abdominal pain or unexplained
hypovolemia + woman of
child-bearing age =
Ectopic pregnancy
Until proven otherwise!
Ectopic Pregnancy
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Management
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High concentration oxygen
IV or IV’s with LR
MAST
Immediate transport
Abortion
Termination of pregnancy
before fetal viability (20th week)
Abortion
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Induced
• Therapeutic
• Criminal
• Elective
Abortion
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Spontaneous
• 20 -25% of pregnancies terminate
spontaneously
• Usually due to embryo abnormalities
• May also result from infection,
unfavorable intrauterine environment,
cervical incompetence
Abortion
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Spontaneous
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Threatened
Inevitable
Complete
Incomplete
Abortion
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Threatened
• Vaginal bleeding, mild or absent
contractions, closed cervix
– 20% of women bleed in early pregnancy
– 50% go on to abort
• Any bleeding in early pregnancy is
dangerous and abnormal
Abortion
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Inevitable
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Vaginal bleeding
Moderately severe contractions
Possible amniotic sac rupture
Cervix effacement and dilation
Changes are irreversible
Abortion
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Completed
• Products of conception expelled
– fetus
– placenta
– decidual lining
• Signs, symptoms
– Profuse vaginal bleeding
– Passage of tissue, clots
– Continuing mild contractions
– Possible hypotension
Abortion
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Incomplete
• Products of conception retained
• Signs, symptoms
– Profuse bleeding
– Passage of tissue/clots
– Severe contractions
– Hypotension, shock
– Sepsis
Abortion
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Missed
• Fetus dies in utero before 20th week
• Retained at least 2 months afterwards
Abortion
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Missed
• Signs/Symptoms
– Continued amenorrhea
– History of bleeding without cramping
– Decrease in uterine size
• Resorption of fluid
• Calcification of products of conception
Abortion
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History
• Confirmed or suspected pregnancy
• Abdominal pain, cramping
• Bleeding, passage of tissue
Abortion
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Physical Exam
• Orthostatic vital signs (tilt test)
• Examine for amount of vaginal bleeding,
presence of tissue
Abortion
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Management
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High concentration oxygen
IV or IV’s with LR
MAST if indicated
Do NOT pack vagina
Save any tissue passed
Transport
Medical Complications
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Diabetes
• Stable may become unstable
• Gestational
• Can not use oral medications
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Neuromuscular
• May be aggravated by pregnancy
Medical Complications
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Hypertension
• More susceptible to complications
– CVA
– Cardiac Failure
– Renal Failure
• May be complicated by preeclampsia or
eclampsia
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Cardiac Disorders
• Additional stress placed on heart
• CO increases 30% by week 34
Pregnancy-Induced Hypertension
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Two Phases:
• Pre-eclampsia
• Eclampsia
Pre-Eclampsia
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In about 7% of pregnancies
Between 20th week gestation, first
week postpartum
Hypertension, albuminuria, edema
Pre-Eclampsia
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Risk Factors
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First pregnancies
Multiple gestations
excessive amniotic fluid
Diabetes mellitus
Renal disease
Pre-existing hypertension
Family history of pre-eclampsia
Poor nutrition
Pre-Eclampsia
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Signs/Symptoms
• Elevated BP
– >140/90 or >30mmHg above patient normal
• Edema of face/hands
– Especially in morning
Pre-Eclampsia
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Signs/Symptoms
• Rapid weight gain
– >3lb/wk - 2nd trimester
– >1lb/wk - 3rd trimester
• Decreased urine output
Pre-Eclampsia
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Signs/Symptoms
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Severe headache
Blurred vision
Irritability
Nausea, vomiting
Epigastric pain
Pulmonary edema
Eclampsia
Pre-eclampsia + Seizures, Coma
PIH
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Management
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High concentration oxygen
IV tko
Left lateral recumbent position
Quiet environment
Reduce excessive light
PIH
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Psychological support
Avoid lights/sirens in pre-eclampsia
Magnesium sulfate
• 4gm bolus; 1gm/hr infusion
• Monitor pulse, BP, respiration, patellar
reflex
• Calcium will reverse toxicity
PIH
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Assess every pregnant patient for:
• Increased BP
• Edema
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Take all reported seizures in pregnant
females seriously
Third Trimester Bleeding
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50% due to normal changes in cervix
50% due to placental catastrophe
Dangerous if amount greater than
normal period
Abruptio Placentae
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Premature placental separation from
uterus
0.4 - 3.5% of pregnancies
Risk Factors
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Older patients
Hypertensives
Multigravidas
Trauma
Abruptio Placentae
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Mild to moderate vaginal
bleeding
Continuous, knife-like
abdominal pain
– Third trimester pain =
Abruption until proven
otherwise
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Rigid tender uterus
S/S of hypovolemia
– Out of proportion to
visible bleeding
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Alteration of contraction
pattern
Placenta Previa
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Placental implantation over cervical
opening
0.5% of pregnancies
Predisposing factors
• increasing age
• multiparity
• previous cesarean sections
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Can lead to
• placental insufficiency
• fetal hypoxia
Placenta Previa
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Painless, bright-red
vaginal bleeding
Soft, non-tender uterus
No contractions
S/S of hypovolemia
Third Trimester Bleeding
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Management
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100% Oxygen
IV of LR x 2
Left lateral recumbent position
MAST, legs only
Assess fetal heart tones?
Third Trimester Bleeding
Never perform vaginal exam on
third trimester patient with
vaginal bleeding
Hyperemesis Gravidarum
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Severe nausea, vomiting
Leads to starvation, dehydration,
acidosis
Continued vomiting in pregnancy
with loss of weight
Hyperemesis Gravidarum
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Management
• Replace lost fluids, electrolytes
• Glucose
Supine Hypotensive Syndrome
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Uterus compresses inferior vena cava
Venous return to heart decreases
Decreased venous return leads to
decreased cardiac output
BP decreases
Consider volume depletion
Supine Hypotensive Syndrome
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Management
• Place patient on left side to restore
venous return
• Transport all non-laboring patients in
late pregnancy on left side
Ruptured Membranes
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Vaginal leakage of clear, colorless fluid
84% labor spontaneously in 24 hours,
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50% become infected in 12 hours
Increased time = Increased infection risk
Patient MUST come to hospital
Fever/Dysuria
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Major medical emergency
Suggests urinary tract or amniotic
fluid infection
Sepsis or early labor may result
Patient MUST come to hospital
Uterine Rupture
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Common causes:
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Prolonged labor against obstruction
Large fetus
Old C-section
Multiple pregnancies
Uterine Rupture
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Signs/Symptoms
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Sudden, intense, tearing abdominal pain
S/S of hypovolemic shock
Loss of continuity of uterine mass
Possible vaginal bleeding
Uterine Rupture
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50 - 75% fetal mortality
Management
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100% Oxygen
IV of LR x 2
Left lateral recumbent position
MAST, legs only
Rapid transport
Uterine Rupture
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History of previous C-section
• Transport immediately unless baby is
crowning
• Determine reason for C-section
Trauma in Pregnancy
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Minor Trauma
• Common in the Obstetric Patient
– Syncopal episodes
– Diminished coordination
– Loosening of the joints
Trauma in Pregnancy
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Major Trauma
• Susceptible to a life threatening episode
– increased vascularity
– may deteriorate suddenly
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Leading cause of maternal death in
pregnancy
MVC’s = 50% of perinatal mortality
Trauma in Pregnancy
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Trauma can lead to
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Premature separation of the placenta
Premature labor
Abortion
Rupture of the uterus
Fetal death
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Death of mother
Separation of the placenta
Maternal shock
Uterine rupture
Fetal head injury
Trauma in Pregnancy
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Injured woman of child-bearing age,
consider pregnancy
Priorities EXACTLY same as in any
other patient
ABC’s first
Trauma in Pregnancy
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Assessment
• Vital signs mimic hypovolemia
–Pulse increases 10-15/minute
–BP decreases
Trauma in Pregnancy
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Assessment
• Blood volume increases up to 45%
• More blood loss can occur before S/S of
hypovolemia appear
• In hypovolemia, blood is shunted from
placenta causing fetal distress
Trauma in Pregnancy
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Assessment
• Increased fluid volume needed to treat
hypovolemia
• Penetrating abdominal trauma in
second, third trimester frequently
involves uterus
• Greatest danger from uterine injury is
hypovolemia
Trauma in Pregnancy
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Assessment
• Second, third trimester blunt abdominal
trauma may cause:
– Uterine rupture
– Placental abruption
– Premature labor
– Hemorrhage from uterine vessels
Trauma in Pregnancy
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Assessment
• “Loose” joints mimic orthopedic injury
• Particularly pelvic fracture
Trauma in Pregnancy
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Management
• Treat shock early, aggressively
– Fetus may be distressed when mother is not
– S/S of shock appear later
– More volume needed to correct hypovolemia
Trauma in Pregnancy
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Management
• Oxygenate aggressively
• Consider assisting ventilation early
– Oxygen demand increases 10-20% in last
trimester
– High diaphragm causes decreased
compliance, tidal volume
Trauma in Pregnancy
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Management
• MAST can be used in late-term
pregnancy
– Inflate legs only
– Using abdominal compartment reduces
blood flow to fetus
Trauma in Pregnancy
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After first trimester never transport
patient flat on back
• Transport on left side
• Prop up right side of spine board with
blanket, pillows
Trauma in Pregnancy
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Most common cause of fetal death
from trauma is maternal death
Keeping mom alive keeps baby alive
What’s good for mom is good for
baby
Braxton-Hicks Contractions
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Usually occurs in the third trimester
Benign phenomenon that simulates
labor
Contractions are generally painless
Walking may help
Preterm labor
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Labor that begins prior to 38 weeks
gestation
Labor results in progressive dilation
and effacement of cervix
Causes
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Multiple gestations
Intrauterine infections
Premature rupture of the membranes
Uterine or cervical anatomical abnormalities
Preterm labor
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Management
• Consideration of tocolysis
– Rest
– Fluids
– Sedation
• Transport for evaluation
Obstetric Patient Assessment
Obstetric PA
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Recognition of pregnancy
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Breast tenderness
Urinary frequency
Amenorrhea
Nausea/Vomiting
Obstetric PA
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Obstetric History
• Gravidity and Parity
– Gravidity = Number of pregnancies
– Parity = Number of live births
Obstetric PA
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Obstetric History
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Last normal menstrual period
Estimated delivery date (-3/+7)
Previous Ob-Gyn complications
Prenatal care (by whom)
Previous Cesarean sections
Obstetric PA
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Obstetric Physical Exam
• Evaluation of Uterine Size
– 12 to 16 weeks: above symphysis pubis
– 20 weeks: at umbilicus
– For each week beyond 20 weeks: 1 cm
above umbilicus
– At term: near xiphoid process
Obstetric PA
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Obstetric Physical Exam
• Presence of fetal movements
– ~20th week
• Presence of fetal heat tones
– ~20th week
– Normal: 120 to 160/minute
Obstetric PA
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Presence of Pain
• Abdominal pain in last trimester
suggests abruption until proven
otherwise
• Appendicitis may present with RUQ
pain
Obstetric PA
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Presence of vaginal bleeding
• Always dangerous in first trimester
• Dangerous in late pregnancy if greater
than normal period
Obstetric PA
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General health
• Diabetes may become unstable
– Hypoglycemic episodes in early pregnancy
– Hyperglycemia as pregnancy progresses
• Hypertension complicated by PIH
• Cardiovascular disease may worsen
Obstetric PA
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Do tilt test if blood loss is suspected
Do NOT tilt patient with obvious shock
Obstetric PA
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Do NOT perform vaginal exams
Obstetric PA
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Warning signs
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Vaginal bleeding
Swelling of face, hands
Dimmed, blurred vision
Abdominal pain
Obstetric PA
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Warning signs
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Persistent vomiting
Chills, fever
Dysuria
Fluid escape from vagina