Obstetrics and Gynecology

1. Obstetrics and Gynecology A lecture about where babies come from Nikhil Natarajan REMT-P

2. Definitions • Fetus – developing unborn baby • Uterus – organ in which the fetus grows, responsible for labor and expulsion of infant • Birth Canal – vagina and lower part of the uterus • Placenta – fetal organ through which fetus exchanges nourishment and waste products while in uterus • Umbilical Cord – cord which is an extension of the placenta through which the fetus receives nourishment while in the uterus

3. Amniotic Sac – the sac that surrounds the fetus inside the uterus • Vagina – lower part of the birth canal • Perineum – skin between the vagina and the anus, commonly torn during delivery • Crowning – the bulging-out of the vagina which is opening as the fetus’ head or presenting part presses against it

4. “Bloody Show” – mucus and blood that may come out of the vagina as labor begins • Presenting part – the part of the infant/fetus that comes first (usually the head) • Abortion – miscarriage – delivery of products of conception early in pregnancy

5. Three Stages of Labor • 1st Stage • Begins with the first uterine contraction and ends with complete dilation of the cervix • 2nd Stage • Begins with complete dilation of the cervix and ends with delivery of the infant • 3rd Stage • Begins with delivery of the infant and ends with delivery of the placenta

6. The OB Kit • Contents • Surgical Scissors • Hemostats or cord clamps • Umbilical tape or sterilized cord • Bulb Syringe • Towels • 2X10 gauze sponges • Sterile gloves • Baby blanket • Sanitary napkins • Plastic bag

7. What can possible go wrong? • Miscarriage • Seizure during pregnancy (Eclampsia) • Vaginal Bleeding • Trauma • Prolapsed Cord • Breech Delivery • Limb Presentation • Meconium Staining • Premature Delivery

8. Miscarriage • Spontaneous abortion • Care • Size up the scene – is it safe? • Initial Assessment • History and PE • Baseline Vitals • Treat the patient based on signs and symptoms • Apply external vaginal pads • Bring fetal tissue to the hospital • Support the mother

9. Seizure during pregnancy • Eclampsia • Care • Size up the scene (ALS?) • Initial Assessment • History and PE • Baseline vitals • Treatment based on signs and symptoms • Transport on left side

10. Vaginal Bleeding • Late pregnancy vaginal bleeding can present with or without pain! • Care • Size up the scene – is it safe? • Initial Assessment • History and PE • Baseline Vitals • Treat the patient based on signs and symptoms • Apply external vaginal pads

11. Trauma • Care for the pregnant trauma patient is the same as for any other patient, except you have two patients! Which one is more important? The mother or the baby?

12. What do I ask? • Are you pregnant? • How long have you been pregnant? • Are there contractions or pain? • Any bleeding or discharge? • Is crowning occurring with contractions? • What is the frequency and duration or contractions? • Does she feel as if she is having a bowel movement with increasing pressure in the vaginal area? • Does she feel the need to push? • Rock hard abdomen?

13. What not to do! • Never touch the vaginal areas except during delivery and when your partner is present • Do not let the mother go to the bathroom • Do not hold the mothers legs together • Recognize your own limitations and transport even if you must deliver enroute to the hospital • Do not flip out! • Do not send your partner to boil some water!

14. The Delivery! • Apply gloves, mask, gown, eye protection for infection control precautions • Have the mother lie with knees drawn up and spread apart • Elevate buttocks – with blankets or pillows • Create a sterile field around the vaginal opening with sterile towels or paper barriers

15. When the infant’s head appears during crowning, place fingers on the bony part of the skull (NOT the fontanelles or face) and exert gentle pressure to prevent explosive delivery. • If amniotic sac does not break, or has not broken, use a clamp to puncture the sac and push it away from the infant’s head and mouth as they appear

16. As the infant’s head is being born, determine if the umbilical cord is around the infants neck; slip over the shoulder or clamp, cut, and unwrap • After the infant’s head is born, support the head, suction the mouth two or three times and the nostrils. Use caution to avoid contact with the back of the mouth

17. As the torso and full body are born, support the infant with both hands BABIE’S ARE SLIPPERY!!

18. As the feet are born, grasp the feet • Wipe blood and mucus from the mouth and nose with a sterile gauze, suction mouth and nose again • Wrap the infant in a warm blanket and place on its side, head slightly lower than the trunk

19. Keep the infant level with the vagina until the cord is cut • Assign partner to monitor infant and complete initial care of the newborn • Place a clamp or tie on the umbilical cord 8 to 10 inches from the baby • Place a second clamp or tie approximately 4 fingers from the baby • After pulsations cease, cut between the clamps or ties

20. Observe for delivery of the placenta while preparing mother and infant for transport • When the placenta is delivered, wrap the placenta in towel and put in a plastic bag and transport it with the mother to the hospital • Place sterile pads over the opening of the vagina, lower the mother’s legs, and help her hold them together

21. As usual, paperwork • Record the time of delivery and what county you are in. Both must be documented on the PCR.

22. Vaginal Bleeding • A 500cc blood loss after the delivery is well tolerated by the mother and is to be expected. Don’t flip out! • If there is excessive bleeding, massage the uterus • Hand with fingers fully extended • Place on lower abdomen above pubis • Massage over the area • If it continues, check technique, provide oxygen and rapid transport

23. Care of the Newborn • Initial care of the newborn consists of • Dry • Warm • Position • Suction • Stimulate

24. APGAR • Appearance • Pulse • Grimace • Activity • Respiratory • Done at 1 minute after delivery and 5 minutes after delivery

25. APGAR

26. Newborn Resuscitation • Breathing effort • If it is shallow, slow, or absent, provide artificial ventilations • Heart Rate • If less than 100 beats provide artificial ventilations • If less than 80 beats and not responding to ventilations begin chest compressions • If less than 60, begin chest compressions

27. Color • If central cyanosis is present with spontaneous breathing and an adequate heart rate administer free flow oxygen (10-15 LPM) using oxygen tubing held as close to the newborn’s face as possible

28. Prolapsed Cord • Condition where the cord presents through the birth canal before delivery of the head; presents a serious medical emergency which endangers the life of the unborn fetus • Care • Standard Initial assessment, VS, and PE • Position the mother with head down or buttocks raised using gravity to lessen pressure on the birth canal

29. Insert sterile gloved hand into vagina pushing the presenting part of the fetus away from the pulsating cord • Rapidly transport, keeping pressure on the presenting part, monitoring pulsations in the cord and keep the cord moist and warm

30. Breech Birth Presentation • Breech presentation occurs when the buttocks or lower extremity are low in the uterus and will be the first part of the fetus delivered • The newborn is at great risk for delivery trauma and prolapsed cord • Place mother in head down position with pelvis elevated and transport rapidly

31. Limb Presentation • Occurs when a limb of the infant protrudes from the birth canal (usually a foot) • Transport rapidly with mother in head down/pelvis elevated position

32. Multiple Births • Call for additional resources • Be prepared for more than one resuscitation

33. Meconium Staining • Amniotic fluid that is greenish or brownish-yellow rather than clear. It is a sign of possible fetal distress during labor • DO NOT STIMULATE the infant prior to SUCTIONING the oropharynx

34. Premature Delivery • Always at risk for hypothermia • Usually requires resuscitation; should be done unless physically impossible

35. Gynecological Emergencies • Vaginal Bleeding • BSI, airway, normal BLS • Trauma • Treat any trauma to the external genitalia as any other soft-tissue injury. Never pack the vagina!

36. Sexual Assault • Criminal assault situations require initial and on-going assessment/management and psychological care • Remember: • BSI • Airway • Non-judgmental attitude during SAMPLE focused assessment • Crime Scene Protection • Examine external genitalia only if profuse bleeding is present • Discourage the patient to bathe, void, or clean wounds • Document very thoroughly!!

37. The End Any questions???