20: Obstetric and Gynecologic Emergencies

1. 20: Obstetric and Gynecologic Emergencies

2. Female Reproductive System

3. Three Stages of Labor • First stage • Dilation of the cervix • Second stage • Expulsion of the infant • Third stage • Delivery of the placenta

4. Predelivery Emergencies • Preeclampsia • Headache, vision disturbance, edema, anxiety, high blood pressure • Eclampsia • Convulsions resulting from hypertension • Supine hypotensive syndrome • Low blood pressure from lying supine

5. Hemorrhage • Vaginal bleeding that occurs before labor begins • If present in early pregnancy, it may be a spontaneous abortion or ectopic pregnancy.

6. Ectopic Pregnancy • Pregnancy outside of the uterus • Should be considered for any woman of childbearing age with unilateral lower abdominal pain and missed menstrual period • History of PID, tubal ligation, or previous ectopic pregnancy

7. Placenta abruptio Premature separation of the placenta Placenta previa Development of placenta over the cervix Placenta Problems

8. Gestational Diabetes • Develops only during pregnancy. • Treat as regular patient with diabetes.

9. You are the Provider • You and your partner are dispatched to the A&E Bank for a woman in active labor. • En route, you discuss previous experiences assisting in a delivery and how you can prepare yourselves. • What equipment should accompany you and your partner inside the bank?

10. You are the Provider (continued) • You find a woman in her mid 30s lying on the couch, holding her abdomen and moaning. • Between labored breaths she tells you that her name is Jane and that she is a teller. • She is conscious, alert, and oriented. Breathing in rapid panting breaths. Pulse is strong and bounding. Skin is pale and clammy. • What questions might you consider asking to assess how far along her labor is?

11. Scene Size-up • Woman’s balance is altered. Be aware for falls and the need for spinal stabilization. • Use BSI. • Usual threats to your safety still exist. • Be calm. Protect the mother and the child.

12. Initial Assessment • Is the mother in active labor? • Evaluate trauma or medical problems first. • Treat ABCs in line with local protocols.

13. Transport Decision • If delivery is imminent, prepare for delivery in warm, private location. • If delivery is not imminent, transport on left side if in last two trimesters of pregnancy. • If the patient was subject to spinal injury, stabilize and prop backboard with towel roll on right side.

14. You are the Provider (continued) • The woman is one week past her due date. She has been having contractions for the past hour. • Her water broke just before your arrival. This is her fourth pregnancy, and she has three children. • She feels like she has to go to the restroom. • Your partner applies high-flow oxygen via a nonrebreathing mask and begins timing her contractions. • What does the patient’s request to go to the restroom indicate?

15. Focused History and Physical Exam • Obtain full SAMPLE history, and also: • Prenatal history • Complications during pregnancy • Due date • Number of babies (twins) • Drugs or alcohol • Water broken • Green fluid (meconium)

16. Focused Physical Exam • Mainly abdomen and delivery of fetus • Based on her chief complaints and history • Pay close attention to tachycardia, hypotension, or hypertension.

17. Interventions • Childbirth is natural, does not require intervention in most cases. • Treating the mother will benefit the baby.

18. You are the Provider (continued) (1 of 2) • You explain that you need to examine the patient before preparing her for transport to the hospital. • While doing so, she tells you that when she went to the doctor yesterday she was dilated to 3 cm and that she lost her mucous plug about one hour ago. • Your partner tells you that her contractions are 45 seconds long and are 55 seconds apart. • Should you check for crowning?

19. You are the Provider (continued) (2 of 2) • Upon examination, you find that the baby is crowning. You and your partner prepare for an imminent birth. • Your partner notifies dispatch and requests ALS backup, and notifies medical control. • You quickly help move the patient to the floor. Using your OB kit, you prepare a sterile delivery field. • Your patient tells you that she needs to push. On the next contraction, the baby’s head is delivered, facing downward. • Why should you feel around the baby’s neck?

20. Detailed Physical Exam • Only if other treatments are not required.

21. Ongoing Assessment • Continue to reassess the patient for changes in vital signs. Watch for hypoperfusion. • Notify hospital of your preparations for delivery. • Document carefully, especially baby’s status. • Obstetrics is one of the most litigated specialties in medicine.

22. You are the Provider (continued) • You successfully deliver a beautiful baby girl. • You have suctioned her mouth and nose, dried her off, and wrapped her in a blanket. • Umbilical cord has been cut and placenta delivered. ALS personnel arrive. • What care should every infant receive?

23. When to Consider Field Delivery • Delivery can be expected within a few minutes • A natural disaster or other catastrophe makes it impossible to reach a hospital • No transportation is available

24. Preparing for Delivery • Use proper BSI precautions. • Be calm and reassuring while protecting the mother’s modesty. • Contact medical control for a decision to deliver on scene or transport. • Prepare OB kit.

25. Positioning for Delivery

26. Delivering the Baby • Support the head as it emerges. • Once the head emerges, the shoulders will be visible. • Support the head and upper body as the shoulders deliver. • Handle the infant firmly but gently as the body delivers. • Clamp the cord and cut it.

27. Complications With Normal Vaginal Delivery • Unruptured amniotic sac • Puncture the sac and push it away from the baby. • Umbilical cord around the neck • Gently slip the cord over the infant’s head. • It may have to be cut.

28. Postdelivery Care • Immediately wrap the infant in a towel with the head lower than the body. • Suction the mouth and nose again. • Clamp and cut the cord. • Ensure the infant is pink and breathing well.

29. Delivery of Placenta • Placenta is attached to the end of the umbilical cord. • It should deliver within 30 minutes. • Once the placenta delivers, wrap it and take to the hospital so it can be examined. • If the mother continues to bleed, transport promptly to the hospital.

30. APGAR Scoring AAppearance PPulse GGrimace AActivity RRespirations

31. Neonatal Resuscitation

32. Giving Chest Compressionsto an Infant (1 of 2) • Find the proper position • Just below the nipple line • Middle third of the sternum • Wrap your hands around the body, with your thumbs resting at that position. • Press your thumbs gently against the sternum, compressing 1/2˝ to 3/4˝ deep.

33. Giving Chest Compressionsto an Infant (2 of 2) • Ventilate with a BVM device after every third compression. • 100 compressions to 20 ventilations per minute • Continue CPR during transport.

34. Breech Delivery • Presenting part is the buttocks or legs. • Breech delivery is usually slow, giving you time to get to the hospital. • Support the infant as it comes out. • Make a “V” with your gloved fingers then place them in the vagina to prevent it from compressing infant’s airway.

35. Rare Presentations (1 of 2) • Limb presentation • This is a very rare occurrence. • This is a true emergency that requires immediate transport.

36. Rare Presentations (2 of 2) • Prolapsed cord • Transport immediately. • Place fingers into the mother’s vagina and push the cord away from the infant’s face.

37. Excessive Bleeding • Bleeding always occurs with delivery but should not exceed 500 mL. • Massage the mother’s uterus to slow bleeding. • Treat for shock. • Place pad over vaginal opening. • Transport to hospital.

38. Spina Bifida • Defect in which the portion of the spinal cord or meninges may protrude outside the vertebrae or body. • Cover area with moist, sterile compresses to prevent infection. • Maintain body temperature by holding baby against an adult for warmth.

39. Abortion (Miscarriage) • Delivery of the fetus or placenta before the 20th week • Infection and bleeding are the most important complications. • Treat the mother for shock. • Transport to the hospital. • Bring tissue that has passed through the vagina to the hospital.

40. Twins • Twins are usually smaller than single infants. • Delivery procedures are the same as that for single infants. • There may be one or two placentas to deliver.

41. Delivering an Infantof an Addicted Mother • Ensure proper BSI precautions • Deliver as normal. • Watch out for severe respiratory depression and low birth weight. • Infant may require immediate care.

42. Premature Infants and Procedures • Delivery before 8 months or weight less than 5 lb at birth. • Keep the infant warm. • Keep the mouth and nose clear of mucus. • Give oxygen. • Do not infect the infant. • Notify the hospital.

43. Fetal Demise • An infant that has died in the uterus before labor • This is a very emotional situation for family and providers. • The infant may be born with skin blisters, skin sloughing, and dark discoloration. • Do not attempt to resuscitate an obviously dead infant.

44. Delivery Without Sterile Supplies • You should always have goggles and sterile gloves with you. • Use clean sheets and towels. • Do not cut or clamp umbilical cord. • Keep placenta and infant at same level.

45. Gynecologic Emergencies • Do not examine genitalia unless there is obvious bleeding. • Leave any foreign bodies in place, after packing with bandages • Treat as any other patient with blood loss.